Lord Forsyth of Drumlean: My Lords, following that point about security, while I understand the need for the security barriers, does the noble Lord sharemy concern about the safety consequences? It is extremely easy for someone to step from the narrow gap in the security barrier straight into the moving traffic and then to step backwards into moving traffic because that is the filter lane out. Having experienced that myself, I think that there is a problem. There is also a problem at the exit from our car park with cyclists, especially at night. It is impossible to see them, because the height of the barriers hides their lights. Sooner or later, there will be an accident, and it would be a great tragedy if we compromised safety in the name of security.

Agriculture: Hill Farming Allowance

Lord Livsey of Talgarth: My Lords, I gather that that is a considered reply. What hill farming in England needs at present is stability. There are cutsin Natural England's budget, as we know, and a delay in environmental schemes coming on stream. Rather than descending into the kind of delays and problems that we have experienced with the Rural Payments Agency, which, even now by Defra's own admission, will not be resolved until 2008, I hope that the Minister's decision will be to continue this scheme to give that necessary stability to those remote areas that will depend on hill farm allowances in the future.

Lord Avebury: My Lords, has the Minister seen the estimate by Human Rights Watch that 82,000 people have been displaced by the current offensive and232 villages have been destroyed? In view of the fact that this is likely to increase the flow of refugees across the border, will he suggest to ASEAN states that they pick up the tab for the 140,000 people who are now being looked after in camps and for the increased commitment to their livelihoods and welfare that has now been expressed by the Thai Government? Should that expense not be borne regionally, instead of by Thailand and the UNHCR?

Lord Warner: My Lords, the work that has been done under this Government has been to build more hospitals with single rooms. There have always been some wards with multiple bays, and they are treated as mixed wards in view of not having mixed sleeping accommodation. I understand the noble Baroness's concerns about her friend. However, I should like to quote the guidance given to the NHS:
	"There are circumstances when admission to mixed-sex accommodation is unavoidable. However, those occasions should be exceptional and patients admitted as an emergency should be moved to acceptable accommodation at the earliest opportunity".
	I fully support that guidance, which was provided by a Conservative Government.

Lord Colwyn: rose to call attention to the current situation in the National Health Service; and to move for Papers.
	My Lords, my noble friend Lady Sharples provided an excellent curtain-raiser to our debate today. I look forward to hearing everyone's contribution.
	Despite the benefit of increased funding and some real improvements, the NHS, which employs more than 1 million people and sees 48 million patients every year, is not well. All over the country, doctors are seriously worried by the continual and rapid introduction of new reforms, fragmentation of services, the lack of evaluation of new policy measures, overemphasis of the role of the independent sector and a lack of vision on the direction of travel. Continual change and reorganisation is having a detrimental effect on the morale of health service staff.
	Essential healthcare professionals are losing their jobs and the NHS now forecasts a gross deficit at this stage of the year of almost £1.2 billion, already very close to the figure of £1.3 billion for the whole of last year. The organisational changes—from regional offices in 1997, via directorates, different numbers of strategic health authorities, and the change from health authorities to 303 primary care trusts, now merged to 130—are hard to understand. One has to ask whether this is good management.
	It is the Government's mismanagement that has put the NHS in this financial mess. Despite all their assurances and promises, and despite the £155 million spent on consultants in 2005-06 and a further £22 million spent on employing "turnaround teams" to support NHS organisations in financial difficulty, they are failingto solve the NHS cash crisis. Last week, a survey of29 accident and emergency departments under threat of closure revealed that 75 per cent of the NHS organisations which manage them were deep in the red in the last financial year. It is of great concern that these closures appear to be taking place for financial reasons rather than on clinical grounds. Just as the Government claim to be bringing care closer to people, they are planning to take local A&E and maternity departments further away. People do not feel safe with this. I hope that the Minister will be able to confirm that any savings made by closing some A&Es will be devoted to building others into specialised centres.
	With more than 20,000 posts being lost, the total cost of NHS compulsory redundancies could rise to £70 million, and with cuts to front-line patient services being made up and down the country, itis becoming very difficult to trust the Labour Government with our NHS. Doctors report on cancelled clinics, empty operating theatres and patient referrals diverted to referral management centres, where patients are often redirected to another consultant's list. The British Medical Association is dismayed by the incoherence of current government policies and the damage they cause to the NHS and the delivery of patient care. Any NHS reform to deliver integrated care must be based on the values of co-operation, strategic planning and equity.
	The recent restructuring of SHAs and PCTs has resulted in a commensurate reduction in the number of directors of public health. It is a concern that, as the timing coincides with NHS deficit recovery plans, PCTs will seek to reduce the number of specialist consultant public health posts. I hope that the Minister can reassure me that this important group of clinicians will be retained so that PCTs can deliver their vital public health functions.
	It has taken a year for the Government to produce their proposals for NHS regulation. But those proposals will fail to ensure value for taxpayers' money and to safeguard the quality of care provided to patients. They do not even address important questions such as what support the majority of NHS organisations can expect if they are in danger of going bust. Under the proposals in the policy document on the future regulation of health and social care in England, the same organisations that have been responsible for presiding over the NHS's descent into financial chaos will have the same responsibilities in future. The same systems that have plunged the NHS into the red today will remain in place tomorrow.
	The review of regulation represents a missed opportunity on a massive scale. It will not give the NHS independence. The NHS tariff will not be set independently, as clearly it should. The competition regime is not to be maintained by an independent regulator; it is a blueprint for continued financial failure in our NHS.
	NHS commissioning that is led by clinicians working together across primary and secondary care will ensure that decisions on health services best meet the needs of patients. GPs should be given back the power to control their own budgets and negotiate contracts with health services, which the Labour Government stripped them of with their abolition of GP fund-holding in 1999. The proposal to introduce a "practice-based commissioning" does not go far enough, since primary care trusts will still be the ultimate statutory budget holders. Government plans to change how NHS services are commissioned could provide a real opportunity to improve the rangeand quality of health service available to patients, but that will succeed only if there is a proper clinical engagement in both primary and secondary care and a meaningful dialogue with patients. The opportunity for every NHS trust to become an NHS foundation trust should be accelerated, and foundation trusts should be given greater freedoms to borrow to invest against their assets. Only this will deliver the flexibility that the NHS needs to finance its future capital investment.
	There is no single cause of the NHS's current financial difficulties but a multitude of local and national factors. Constant reform and political interference have taken their toll, as have difficulties in managing deficits and strategic planning failures. The impact of NHS deficits in England has been wide-ranging for both patients and NHS staff. A BMA survey in 2005 revealed that one in three NHS trusts planned to reduce services because of deficits. Of the 171 NHS trusts that replied, one-third reported that their trust intended to reduce patient services. The Audit Commission's recent report on financial failure in the NHS found that organisations in financial difficulty routinely failed to engage senior clinicians in management decisions. This came as no surprise to doctors' leaders who have consistently called for greater clinical engagement in policy development and implementation. A criticism of engagement is that it comes too late in the process of developing policies or solutions to problems. All too often, Ministers will come up with a policy and then consult stakeholders about how to implement it. Doctors and other healthcare professionals should be engaged constantly in policy development to jointly analyse problems and co-produce solutions.
	One major concern that health service staff have with the involvement of the private sector in the NHS and particularly independent sector treatment centres is the impact on local health economies. In some cases ISTCs have been imposed on local areas where their capacity was not needed or wanted. Health managers diverted resources for certain operations which had a negative impact on the existing local NHS services which were already performing these operations.
	The concern is not that ISTCs exist, but that they exist in isolation from the NHS. There is a concern that the involvement of the independent sector has been implemented without provision for co-operation with existing NHS services, with preferential arrangements. This has the potential to threaten core NHS services. Medical centres operated by private health companies are treating as few as a quarter of the NHS patients whom they have been paid to handle. However, under contracts worth £1.7 billion given to companies to operate 18 centres since 2004, the money is paid whether targets are met or not, resulting in millions of pounds of taxpayers' money being wasted. I understand that the Department of Health has just signed new contracts worth £200 million with 14 private healthcare companies, which are to provide an additional 750,000 medical procedures.
	Local financial difficulties have been compounded by national policies. The Government's commitment to commercial sector involvement in the NHS and the strain this puts on NHS finances is a key example. The preferential contracts awarded to commercial companies to carry out NHS work have meant that NHS hospitals lose out on essential funding. ISTCs are using NHS millions when spare capacity in the NHS goes unfunded and unused. PFI projects and the use of expensive management consultants are similarly draining vital funds from the NHS.
	I am in favour of using the private sector, but the Government have clearly involved the independent sector without delivering value for money. Centres are not working to their optimum capacity and cost significantly more than the same service provided by the NHS. With the NHS in England recording a net deficit of £547 million in 2005-06, the suggestion that the NHS has had its best year ever must be disputed. This year has seen vital healthcare professionals losing their jobs, cuts in training budgets and doctors reporting cancelled clinics, ward closures and delayed operations. The Government have invested unprecedented funds in the NHS, and profound changes are taking place with virtually no debate in Parliament and without full and proper consultation with staff, their representative organisations, patients and the public.
	With the current financial instability in the NHS, medical education and training in England are increasingly coming under threat, and this may affect patient care. Budget cuts to fund NHS deficits are draining vital resources from training and education for medical and dental students and threatening academic jobs. Continued cuts to training and education will threaten numbers of medical school places, worsen shortages of clinical academic staff and could result in the closure of some schools. Targets for the cuts include funding for junior doctors' study leave, which allows them to attend courses required for their training. These cuts are increasingly regarded as the soft option for trusts facing financial pressures, especially as they are no longer ring-fenced.
	The NHS has a shortfall of doctors relative to demand. By 2008, the UK will need about 25,000 more doctors than it did in 1997. It is essential that the budgets, held by special health authorities, are protected. I should be grateful if the Minister could say what steps are being taken to ensure that clinical academic posts are not affected by NHS financial deficits and the non-ring-fencing of the multi-professional and education training levy.
	I could not initiate a debate on the NHS without mentioning my own profession of dentistry. The reforms to NHS dentistry have not improved access for patients, and the Government have accepted that2 million people who wanted to see an NHS dentist prior to 1 April this year are still unable to do so after the implementation of the new contract. About90 per cent of dentists signed the new contract, but about 1,700 who previously had an NHS commitment did not. Many contracts were signed in dispute and the latest figures show that about 1,130 of these are still unresolved. I made some comments about the current dental situation in the debate on the Queen's Speech and it is not my intention to repeat the issues that I raised. I must, however, try to clarify the situation regarding my assertion that the drill and fill treadmill has been replaced with a new treadmill, one driven by targets which are not patient-centred.
	When this came up in Questions in your Lordships' House on 21 November, the noble Lord, Lord Warner, was positive that this treadmill has been removed, but he must agree that the system does nothing to encourage dentists to take on new patients. Those patients, who may not have seen a dentist for several years, are much more likely to need more dental treatment than the patients who attend regularly and can benefit from advice on the maintenance of good oral health. Where is the incentive to take on new patients when the examination, scaling and perhaps one filling in one patient and the same examination, scaling and need for multiple fillings in another attract the same number of units of dental activity?
	I am aware of dentists who have to see between35 and 50 patients per day to meet their contractual targets. The meeting of the British Dental Association parliamentary panel last week was informed of one dentist who had to see up to 90 patients per day to meet her UDA target. Under the piloted personal dental service scheme, dentists had the freedom to commission services to meet local need. It was possible to ring-fence time for emergencies, meaning that patients with an emergency could have the full treatment on the first visit, rather than having to arrange another time some weeks ahead. Once an NHS dentist has met their target, they will not receive funding for any further treatment they perform that year. It is of great concern that some dentists may meet their target early and then be unable to provide patients with the NHS treatment that they need and which the dentist has capacity to deliver. I suggested that the Government regard the first year of the new contract as a test year. I believe that the figures for the first year will not be available until June and thatthe Government are committed to producing a report on the first 12 months based on the work of the implementation review group. This will enable a thorough review of the effects of the new contract. That opportunity must be grasped.
	Any changes that improve patient care should be supported, but the Government should do more to recognise the progress made by their extra money and the hard work of NHS staff, and should make sure that change and reform involve support from the staff who have to deliver it. The NHS has repeatedly demonstrated its ability to foster innovation and is a proven mechanism that can deliver, and has delivered, reform. Reform must be based on the values of co-operation, strategic planning and equity and should deliver integrated care and an environment in which teaching, training and research can flourish. I beg to move for Papers.

Lord Rodgers of Quarry Bank: My Lords, I welcome the initiative of the noble Lord, Lord Colwyn, in raising today's debate. Shortly before the most recent general election, I recall another debate in the House to which I listened but in which I did not participate. Almost all noble Lords who spoke had been professionally involved in the health service and were well disposed to the NHS, saying that so many things were getting better. After the bleak Thatcher era and Gordon Brown's four lean years of public expenditure, there was now a perceptible improvement.
	On the occasion of today's debate, the moodmay be a little different. Last year, I did not quarrel with the apparent consensus. My knowledge and experience arose entirely from me and my family, and we were glad that the NHS was recovering. However, I thought that the debate was rather too full of self-congratulation and provided too little recognition of the gap between the much-improved NHS and the so-called world class to which the Government had chosen to aspire. The glass of success was half full, but it was still half empty.
	As an example, I had applied at that time for my NHS hearing aids. In the House, Ministers proudly told us of the new digital appliances—the result of a successful deal between the public and private sectors. But I then discovered that fitting my hearing aids would take a full year, and elsewhere the delay was often very much longer. For those who had hearing problems, the glass was certainly still half empty.
	I want to deal mainly with another current issue—the future of stroke care—and, again, I shall draw from personal experience. Today, I am not pursuing the subject of the highly controversial accident and emergency proposals spelt out by the Prime Minister this week, although I am not yet persuaded of their virtues. On 23 May, in a short debate, I had the opportunity to raise the National Audit Office report of November 2005, Reducing Brain Damage: Faster Access to Better Stroke Care. I explained that five years ago, I had been taken to the Royal Free Hospital, London, and then to the National Hospital for Neurology and Neurosurgery in Queen Square. A stroke had been diagnosed.
	The National Audit Office report, the Houseof Commons Public Accounts Committee report which then followed, and the Government's recent response—the 52nd report, Cm 6924—have this in common: they agree that stroke is the single biggest cause of death after heart disease and cancer and that three times as many women die of a stroke as die of breast cancer. Nor does the department dissent from the PAC's conclusion that stroke costs the economy £7 billion a year, including £2.8 billion in direct care costs to the NHS.
	I shall not set out further the large measure of agreement between the three reports on matters of fact. I concede that there have been significant improvements in the past five or six years and that stroke is now accepted as a medical sub-specialty, but I am unhappy about the tone of the 52nd report, which is bland, the lack of urgency on the part of the Department of Health and the apparent absence of additional resources sufficient to implement good intentions. In particular, I am greatly concerned about the arrangements necessary for scanning stroke victims.
	The summary of the National Audit Office report said:
	"There are barriers that prevent stroke patients from receiving rapid and responsive emergency care".
	It continued:
	"Large numbers of acute stroke patients don't get a scan within the critical time period".
	Among the conclusions and recommendations in its report, the PAC said:
	"All suspected stroke patients should be scanned as soon as possible after arrival at the acute hospital, ideally with three hours, and none should wait more than 24 hours".
	The Department of Health agrees with the recommendations, and that is fine, but there is too little evidence in the report that serious progress is being made.
	In my speech on 23 May, I drew attention to my interest in the Royal Free Hospital—one of my local hospitals. So, a couple of months later, I asked the Royal Free whether patients were scanned within three hours and whether they could be scanned 24 hours a day, seven days a week. In his reply on 22 August, the chief executive of the trust said that the hospital had the facility to scan patients 24 hours a day, seven days a week, and its aim was to scan within 24 hours of admission. But the hospital could not routinely scan patients within three hours and, in the last audit period, 10 out of 33 acute stroke patients were not scanned within 24 hours.
	I am not making a target of the hospital. On the contrary, the chief executive gave a straightforward answer to my questions. But my guess is that the Royal Free is typical, plus or minus.
	I am not asking the Minister to give an authoritative view this afternoon—that would be unreasonable—but I will table a Written Question to him to give me a complete picture, hospital by acute hospital, in answer to my two simple questions.
	On access to stroke care, I am ready to concede that the glass is now half full, but I hope that in turn the Minister will concede that it is still half empty.

The Lord Bishop of Worcester: My Lords, I am grateful to the noble Lord, Lord Colwyn, for initiating this debate. It is clear from the three speeches already made that it will be a very wide-ranging and searching one.
	I have come to take part in it because I hope to have some answers to some puzzles. I am genuinely puzzled and I look forward to hearing some resolution to them from the Minister and others.
	It is clear that an enormous amount of additional resource has been put into the National Health Service. To deny it would be churlish and would fly in the face of the facts. The results are, in part, there to see, and one has to be grateful for that. My puzzle is that, on the other side, there seems to be a financial regime so draconian that people are asked to cure deficits within quite unreasonable times with disastrous results on any sensible scale of planning that they might have had.
	Here is another puzzle. We have a wonderful, new-looking hospital in Worcester that we are told was put up without any impact on the public sector borrowing requirement. But we notice that in the deficit that has to be dealt with, a large part is owed to the company that built the hospital. Therefore, for all intents and purposes it looks exactly like a debt. We used to buy things on hire purchase more than we do now, and we always thought that that was a debt. I am a bit puzzled that something that feels like a debt, looks like a debt, and walks like a debt is not a debt.
	We are told that there is greater devolution of authority to local trusts. Indeed, the Minister who will be responding has told me on more than one occasion of the importance of this policy of local decision-making. But experience on the other side is different. When I go to the local trust, it says that itis required by the Government to do certain things that it wishes to question. As to the localness of decision-making, the trusts appear to be free to make decisions that do not have the support of any of the democratically elected authorities in the area. Those authorities have great difficulty in even raising questions. That is a puzzle.
	I shall make some points about targets. Targets are another puzzle. I understand what the Minister said in response to the Question asked earlier by the noble Baroness, Lady Sharples. He said that targets have an effect on priorities and bring about the raising of certain standards. But where are the targets for quality, gentleness, attentiveness, waiting or listening? Where are the targets that relate to the heart of the service?
	Noble Lords will understand that I do not wish to say very much today about the particular chaplaincy crisis facing Worcestershire because this is the very day on which the board of the trust is meeting, and it may yet be possible for there to be some acceptable compromise. I very much hope that there will be, and I do not wish to say anything that might make that more difficult. That crisis is an instance of the absence of any will to enforce targets for the heart of the service. I want the Government to give that some attention.
	The priest responsible for National Health Service matters in a diocese in which I previously worked was taken around a hospital by the chaplain. They entered a ward that was clearly in crisis—such things happen. People were rushing about in great distress; it appeared that matters were out of control. My friend turned to the chaplain and said, "What on Earth could you possibly do in a situation like this?". The chaplain replied, "Just walk slowly".
	There needs to be a target for walking slowly. In most situations, that will be the only way to allow the reality of a person's illness, the reality of what staff are up against, to become clear. Chaplains, and their support across the faith communities, are part of that heart, as is nurse training, which we have heard is in some danger.
	We have all been ill and we know that it is quite difficult to speak clearly about what is wrong with you unless somebody is spending time on it. I am not against targets, but I would like to see a target for spending "long enough" with a patient, not just ones that say how many patients you have to see.
	The National Health Service is something of which we are not only proud, but for which we are hugely grateful. I am concerned about its heart, and some of my earlier puzzles are to do with that heart being in some danger. A National Health Service where nobody is asked to walk slowly is not one that will ultimately do us any good.

Lord Layard: My Lords, I shall talk about the problems of those with depression and anxiety disorders. First, I praise the huge improvements in the NHS under the present Government. It was an extraordinary and momentous decision to raise our spending to the European level. No other Government would have done it, and the benefit to patients has been enormous.
	That is true of mentally ill people in the secondary sector as well as the physically ill. Compared to 1997, the secondary mental health services employ 50 per cent more psychiatrists and 75 per cent more clinical psychologists. Of course, the premises have oftenbeen transformed beyond recognition. However, the secondary mental health service provides for only about 1 per cent of the population—chiefly those who suffer from the serious conditions of schizophrenia and bipolar disorder. Another 16 per cent of the population suffer from clinical depression and chronic anxiety disorders, which can cripple their lives—one need only think of the hundreds of thousands who cannot even leave their homes.
	That 16 per cent have always had a raw deal from Governments of all persuasions. For most of them, all that has been available has been either medication or, possibly, a little counselling. This provision is completely contradictory to the NICE guidelines—an extraordinary situation of which people may not be aware. The NICE guidelines recommend that, except where the condition is very mild, all those with these conditions should be offered modern, evidence-based psychological therapies. That guideline is based on hundreds of random assignment control trials which show that after less than 16 sessions of cognitive behavioural therapy, for example, half of all who suffer from these conditions will be cured. In addition, surveys show that patients want psychological therapy more than anything else. It is not expensive: the average cost is about £750. Is it not dreadful to think that millions of people in misery could be relieved by so little expenditure? It is even more shocking when we realise that the net cost of doing so is nothing because 1 million of those people are on incapacity benefit and being on that a month rather than working and paying tax costs £750, which is the same as the cost of a course of therapy. Huge savings could be achieved through more widespread provision of psychological therapy according to the NICE guidelines. I am not saying that we should treat people simply to save money—far from it—but if we can relieve misery and at the same time save money, it is a powerful argument for quick government action. On any reasonable calculation, it would cost the Government nothing net to implement the NICE guidelines in this area.
	Implementing the guidelines on depression and anxiety disorders must be a top priority for the Government's forthcoming comprehensive spending review. The aim must be to create an evidence-based psychological therapy service within every PCT to which GPs and jobcentres can refer their clients. That is what GPs want. They complain all the time about the absence of such a service, and the proposals put forward in The Depression Report, published by the London School of Economics, were backed by the Royal College of General Practitioners and the GP representatives of the BMA. The main danger is a dumbed-down response providing therapy on the cheap by inadequately trained people offering too few sessions aimed at improvement rather than cure. That would be false economy and is not based on the evidence. People who have these conditions should be treated as we would like to be treated if we had them. That should be the fundamental principle in the treatment of mental illness. For 50 years or so, it has been the fundamental principle in the treatment of physical illness, and it should apply to mental illness just as it applies to cancer. We must get rid of the remnants of the do-it-cheaply, poor-law thinking that we abandoned for physical illness 50 years ago.
	We need an adequately trained workforce. One estimate is that we need approximately 8,000 more therapists than are now in the service. It is obvious that this problem cannot be dealt with overnight, and nobody is saying that it should be dealt with in the middle of this financial crisis. It should be dealt with by a phased seven-year plan. We have to have a clear concept of where we want to get to at the end, so it is necessary to start at the end, not the beginning. First, we have to decide what is an acceptable service; secondly, there needs to be a commitment to getting there by, I suggest, 2013; and, thirdly, there needs to be a national training plan for making that possible. All that needs to be spelled out in the settlement before the Comprehensive Spending Review.
	This is a long-standing problem that has been ignored by Governments of all persuasions and, in fairness, I should add that the NICE guidelines in this area are only three or four years old. However, they are breached to a degree quite unknown with any other form of illness. To get a change of approach, we have to have a different perspective on mental illness. We need to recognise that mental illness is one of the main forms of deprivation in our society. Research shows that it causes more misery than poverty or physical illness. If we can recognise that mental illness is a major form of deprivation, I am sure that it will become a central policy issue in the years to come. Now is the time not only to plan for action but to begin it.
	Mental illness has been with us since the Stone Age. What is new is that we now have the techniques for tackling it. It would be hard to forgive a Government if they did not rapidly make those techniques available to people who so desperately need them, especially when it would cost nothing.

Lord McColl of Dulwich: My Lords, I, too, welcome the initiative of my noble friend Lord Colwyn in securing this debate. I should like to draw attention to the trafficking in human beings, which has such a serious effect on the health of its victims. The United Nations has defined trafficking in human beings as,
	"the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat of use of force or other forms of coercion, of abduction, of fraud, of deception ... for the purpose of exploitation. Exploitation shall include .... prostitution ... forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs".
	People trafficking is a global issue that affects virtually every country worldwide. An article in the Herald Tribune this week reports that the Council of Europe estimates that people-trafficking revenues have reached a staggering $42 billion. Nearer home,it is rather worryingly reported that an average of100 unaccompanied minors come through UK immigration at Lunar House in Croydon each week. Of those, some 80 disappear. The strong belief is that most are taken by traffickers.
	It is common practice for traffickers to make trafficked people memorise a phone number before they leave their country of origin, even though they do not know why. These people are often abandoned at the departing airports with their only option being to carry on with their journey. On reaching the UK, they expect—this is the deception—a helpful person to meet them and to provide them with the job that they were promised. When they arrive alone, the Immigration Service has to refer them to the police or social services and they are temporarily housed until, usually, they are flown back to their port of embarkation, where the traffickers are often waiting to retraffick them. This can happen 20 times in their lives. Often, before these people are sent back, they call the memorised phone number and are picked up by the traffickers in the UK. The police and social services have no idea of their whereabouts.
	The effect on women of being trafficked is absolutely devastating. A report by, among others, the London School of Hygiene and Tropical Medicine, concluded:
	"Trafficking often has a profound impact on the health and well-being of women. The forms of abuse and risks that women experience include physical, sexual and psychological abuse, the forced or coerced use of drugs and alcohol, social restrictions and manipulation, economic exploitation and debt bondage, legal insecurity, abusive working and living conditions, and a range of risks associated with being a migrant and/or marginalised".
	In that study on violence and injury during trafficking, 95 per cent of respondents reported physical or sexual violence, 90 per cent reported being sexually assaulted, 75 per cent reported being physically hurt, 36 per cent reported receiving threats to their family, and 77 per cent reported having no freedom of movement. Those who had a degree of freedom generally described being accompanied by minders to prevent their escape. To retain control over each woman, traffickers, madams or pimps create an unpredictable and unsafe environment to keep them continually on edge. Most of the women were also denied access to healthcare during their experience. Immediately following their release or escape, most of them are burdened with numerous and concurrent physical and mental health problems.
	What is the extent of human trafficking? At least12 million people are victims of forced labour worldwide. Of those, 2.4 million are in that situation as a result of human trafficking. Eight hundred thousand women, men and children are trafficked across international borders each year. That is one person trafficked every minute. Approximately 80 per cent of those trafficked are women and girls. Up to 50 per cent of them are minors. An estimated 1.2 million are children. The majority of these victims come from the poorest countries and the poorest strata of the national population. Trafficking is the fastest-growing means by which people are caught in the trap of slavery.
	We have no reason to be complacent in this country, bearing in mind that, quite apart from trafficking, 10 per cent of children are sexually abused. In 1998, the Home Office estimated that several hundred people being trafficked per year were forced into prostitution. In 2003, the figure rose to 2,800 and, last year, it was 4,000. What is the Department of Health doing about these health problems?

Lord Addington: My Lords, I thank the noble Lord, Lord Colwyn, who is my friend, for bringing this debate before us today. I want the House to consider another aspect of healthcare where the NHS is rather underperforming: sports medicine, or, to use the correct term, sports and exercise medicine. From doing a little research, I discovered that there are currently only three consultants working in the NHS in that field. It is reckoned that we need a number in the mid-30s to provide basic coverage. According to some doctors in the field to whom I have spoken, at the current rate of training, we will get about a dozen by 2012.
	Those statistics mean nothing unless I explain why the issue is important. Sports and exercise medicine is probably what will enable us to maintain a drive for greater physical activity among our population. The Minister for Public Health and the Minister for Sport are so often seen together at events because we recognise that greater physical activity has huge health benefits across the board. Many conditions, including most forms of cancer, are much less likely if you are reasonably fit. As for how you measure that, I have indulged in attacking the body mass index in the past, so I will not go into that again, but I know that someone who is fitter is at much less health risk.
	How do we keep someone healthy? We can tell them to go jogging 2.3 miles three times a week, to eat less, to live a virtuous and moral life and not to watch TV too often, but we will fail. We already have. If we get people interested in a competitive form of physical activity—sport—they have an incentive to keep themselves fit. They will not be bored by the process. If noble Lords want proof of this, they need only look at the exercise industry. The way in which most gyms make money is that we all join in January, turn up three times, and forget that they are there by February. The industry itself is pretty open about this, to be perfectly honest. We need a way of keeping people interested, but once we have got them interested—this applies much further down the socio-economic chain and probably in this Chamber, too—we must ensure that they can afford to be fit. By that I mean that people must know how to be fit and how to maintain fitness without fear of injury.
	Many of my rugby-playing days were spent at a small club in Norwich. We lost players regularly because they could not afford to be injured. They clamber up and down a roof to do various jobs and cannot afford that knock on the ankle or the bang on the hand. They can no longer take the chance and miss two weeks' work. As has already been mentioned, if you happen to be medically incapacitated and are on benefits, everything suffers. If we can get a better structure of support from the NHS, these people will be much more likely to carry on. They will also carry on if they receive better help to change their exercise patterns as they get older.
	The main thrust of what I am trying to say isthat the NHS does not seem to engage in this process of enabling people to maintain exercise in an environment that will encourage them to maintain it. Much of the current thinking about sports science derives from the huge amounts of activity in the private sector devoted to elite-level athletes, who are in effect of another species, both physically and behaviourally, so they are not really my concern here. The fact that Michael Owen may have to go abroad to get his knee dealt with may be an affront to the ego of certain specialists in the field, but it means absolutely nothing to the person who runs out on a Sunday-morning side to play soccer. My concern is about maintaining that sort of exercise.
	We are not getting the support and knowledge within those medical professions at the front end. It is down to the NHS to maintain this support, but the structures are not there. People are still told to rest when they have an injury, but that will weaken muscles and shorten tendons, which means that they are more likely to be hurt when they go out again to play. Unless we start to address this by having greater levels of knowledge—this will start with pressure and information coming through from consultants—we will not be able to maintain people's activity at the proper rates. The advantages of greater physical activity will dwindle, and no matter how much we pontificate and tell people to engage in it, there will come a point when they say, "How do I do it? Something has gone wrong with my life. How do I get back?".
	I have ignored the fact that it simply hurts to have an injury, and it will carry on hurting if it is not treated properly. But my main experience in talking to people doing various types of sport is that it is often the fear of losing income that stops them playing. If we can somehow address this, we will back up many of the other good schemes. The question that I really want to ask the Minister is—and I think that I will have to ask it again on other occasions, because it is a bigger subject than I initially thought—what is the Government's thinking on bringing sports and exercise medicine much more into the mainframe of the NHS, particularly at the initial point of contact, the GP?

Lord Parekh: My Lords, I, too, thank the noble Lord, Lord Colwyn, for initiating this very important debate. I would sum up my answer to his question about the state of health of the NHS in one sentence: it is undergoing some convulsions but its life is not in danger. The NHS has made considerable progress while the Labour Government have been in charge of it. If one looks at certain obvious statistics one sees that since 1997 we have gained 50 per cent more consultants, 35 per cent more clinical support staff,35 per cent more hospital doctors and 34 per cent more GPs. But those are bare statistics. In a very important way there has been a profound cultural change in how the NHS has been constituted in the past few years. Patients feel that they are valued and at the centre of attention and they know their rights, and medical staff are aware that they are accountable to patients and to other bodies for what they do. Many of us who have been around for quite a while have been feeling these profound changes in the NHS. So while I compliment the Government on all that they have done, I want to highlight four or five important issues that worry me a little.
	First, the results of the expenditure of resources do not seem commensurate with the amount spent. For example, GPs have been given very generous contracts—and I spend all my time among friends and relations who are GPs. On average, they earn about £100,000 to £125,000 a year, a figure which we professors simply envy. I do not begrudge them at all, but I think that in return for that one could expect that the range of services would be wider, the premises more efficient and the services offered to patients administratively more competent. I do not see those changes. And it seems the same with NHS trusts. They have been given a considerable amount of money and freedom to run their affairs but their administrative and management capacity, especially in matters financial, has not kept pace with the amount of responsibility they have been given. I do not know how much attention is being paid to ensuring that the people in charge are suitably trained.
	Secondly, there are two conflicting considerations on the reorganisation of hospitals which are not easy to balance. It is right that the latest medical technology should be concentrated in a few centres, for obvious professional as well as financial reasons. It is also important that there should be supra-regional accident and emergency departments concentrated in certain places, and, pari passu with that, some should be downgraded. While that is necessary, it is also important to bear in mind that it conflicts with patients' preferences and needs. Patients do not feel safe without access to an accident and emergency department that they can reach within a reasonable time. They also prefer to have babies in local maternity units. It causes anxiety to downgrade such facilities to a single midwife-led unit. We therefore have to find ways of balancing the need to concentrate medical and professional resources in certain regional centres with the need to provide local centres. The Government seem to think that smarter communication might solve the problem but I do not think that it is as simple as that. These two considerations have to be reconciled in the light of local circumstances. In taking such decisions, a great deal of attention should be paid to the views of patients, the public and doctors. They should be involved in taking decisions of this kind.
	My third concern has to do with the independent sector treatment centres. I am not against the private finance initiative but I have some grave anxieties. In this case, they are poorly integrated into the NHS and do not train doctors in the same way as hospitals. There is too much reliance on foreign—in some cases, overseas—staff. We do not seem always to get value for money. These independent centres also enter into long-term contracts which are not easy to change. I would suggest that, although they are necessary to deal with the backlog, our overall strategy should be to concentrate on expanding NHS facilities rather than relying on centres of this kind.
	Fourthly, as the noble Lord, Lord Crisp, said, rationing in one form or another is insuperable. But we must bear in mind that there is an unholy alliance of drug companies, populist media and some groups of politicians who seem to want to make sure, sometimes against the advice of NICE, that certain drugs that might not be recommended becausethey create a certain amount of popular scare should be widely available. NICE took a very firm stand on, for example, the flu drug Relenza and faced down Glaxo, which had threatened to leave the country. Decisions on rationing are inevitable. Rather than the Government leaving these decisions entirely to NICE, it is very important to involve medical staff who could explain why certain decisions have been taken.
	Finally, noble Lords will expect me to say something about the important issue of the ethnic minorities. Their representation on NHS trusts falls far below their number in the country at large and their presence in the profession. How many chief executives are drawn from ethnic minorities? How many people from ethnic minorities are on NHS trust, foundation trust and PCT boards? I would like to know how many members of the NHS Appointments Commission are drawn from the ethnic minorities.
	In many areas we are beginning to find that there are redundancies and the contracts of doctors and nurses are being terminated. People who have been in training for some time are being told that they may not be able to get jobs commensurate with their qualifications. Some of my close consultant friends tell me that the burden of redundancy is likely to fall disproportionately on ethnic minorities. I should like to be reassured by the Minister that that is notthe case and that, should it happen, there will be enough provision to ensure that such decisions are countermanded.
	I have full faith in the Minister and the Secretary of State for Health but suggest that the style of administration and the mode of decision-making they have inherited during the past 10 to 15 years need to be radically changed. The NHS is a Labour creation and something to which the party has been strongly committed. It would be a great pity if people felt that they could not trust the Government or the party with the safeguarding of the NHS.

Baroness Murphy: My Lords, we have many opportunities in this House to consider the NHS but, like many others, I thank the noble Lord, Lord Colwyn, for raising this debate at a time when the media are full of their favourite scare stories and so many Members of the other place are having such sport in their own constituencies. There is no greater gift to Back-Bench politics than a nice hospital-closure scare. However, first let me declare my interests as chair of council at St George's, University of London, and as a board member of Monitor, the NHS foundation trust regulator.
	I had an opportunity in the debate raised by the noble Lord, Lord Rea, only a couple of weeks ago to express my strong support for government policy in pressing on with the increased independence of providers, plurality of provision and encouragement for private sector competition. I also strongly support the emphasis on increasing productivity and cost-effectiveness.
	It is a sad fact of life that, as currently structured, the only time the NHS undertakes necessary service restructuring and modernisation is when it is short of money. The current proposed reconfigurations are not the outcome of a cost-cutting exercise; rather, they are changes that should have been put in place years ago but were deemed to be politically undeliverable at the time. My noble friend Lord Crisp will remember well his reaction, and that of Ministers, when my strategic health authority wanted to join up two tiny primary care trusts in north-east London to match the borough boundaries. The notion that we might propose to reconfigure large services, such as maternity services, which needed doing very badly, or whole hospitals was out of the question.
	I too am attracted to the notion that we should get some kind of distance between the Department of Health and the overall management of investment in the NHS. Perhaps we might like to look at the model of the Higher Education Funding Council for England, which purchases higher education places but leaves a measure of independence to providers. That is quite a good model.
	My concerns about the proposed reconfigurations are whether political courage will be sustained long enough to implement the necessary changes—time and again I have seen Ministers cave in to Back-Bench pressure—and whether the service cost and quality information is sufficiently robust to allow sensible decisions to be made. The detailed data are notthere, although I believe they could be fairly quickly. At Monitor we have been doing some pilot workon service-level economics that provides some fascinating insights for the participating foundation trusts and allows far better strategic planning of future service delivery and cost improvements. Hospitals are not homogeneous entities; neither are community services. Even the worst basket case of a DGH—and there are some—contains some service gems. Ensuring that they survive and flourish will be a challenge. What progress is being made to help NHS trusts move their accounting systems towards service level costings? If none, on what basis are decisions being made?
	I turn to budget raiding by strategic health authorities, the age-old, lazy way of balancing budgets in the NHS in order to prop up the voracious acute hospital sector. That is Enoch Powell's phrase, by the way, not mine. It is happening to education and training budgets and to mental health services. My noble friend Lady Meacher mentioned this issue in her excellent maiden speech on the gracious Address. Mental health trusts generally stay within budgets when other acute hospital services do not. We heard her say that nearly £4.6 million is coming out of the revenue budgets of East London and the City Mental Health Trust, which serves the most needy area in the UK. The noble Lord, Lord Layard, has set out for us today the huge need in mental health outside the existing mental health trusts. That need will not be met by the current way of dealing with mental health budgets. A survey carried out by the Sainsbury Centre for Mental Health in July found that nearly two-thirds had been asked to cut their budgets to cover overspending in other areas.
	The second area being raided is education and training budgets for nursing, midwifery and allied health professionals. Over 10 per cent has been cut from training budgets this year, although it is much worse for universities in some areas, notably the east of England, and strategic health authorities in London and the south-central and south-west regions, which are also predicting larger reductions for 2007-08.
	The current numbers of unemployed newly qualified nurses are due to NHS posts suddenly being frozen for financial reasons, not because of any serious reconsideration of staffing requirements or oversupply of graduates. If the numbers of new students continue to be reduced, that will lead inevitably to a boom-and-bust scenario even worse than we experienced in the 1990s. We have seen that cycle before, and it is coming around again because of short-termism. What are the Government doing to ensure that this all too easy budget raiding is stopped?
	Finally, I come back to mental health services, particularly those for older people. That is my own speciality, and I have therefore been circumspect in talking about it in this House. It is clear from work done by Professor David Challis's group at the PSSRU in Manchester that progress on the five year-old National Service Framework for Older People has been very slow. Many community teams still lack core team members, such as psychologists, and indeed social work input has gone down in the past five years. Where protocols for referral exist, they are rarely used by GPs, and the single-assessment process, which we all wanted and pressed for—indeed, some of us were running them back in the 1980s—has developed into a bureaucratic nightmare that has not led to real service improvements. One-quarter of services have inadequate community resources to sustain people at home.
	Management focus on these services is extremely poor, even though the patients often have the most complex family needs. Adult general psychiatry services have mopped up the extra investment in mental health so that older people's services therefore remain old-fashioned and largely bed-bound, with resources locked up in the wrong place. It is time we looked at how we can get the balance right when most of the mental health admissions to hospital are for people over 65. What are the Government doing to promote better services for older people with mental health problems?

Baroness Masham of Ilton: My Lords, there is no doubt in my mind that the National Health Service is a high priority on many people's agendas. The sister of one of my Cross-Bench colleagues came up to me in Yorkshire last Friday, without knowing that this debate was about to take place, and said "I hope you are supporting the NHS. We need reliable, good services near our homes". As many community hospitals are having to cut beds and some are closing, this is a worry across the country for the increasing elderly population. I thank the noble Lord, Lord Colwyn, for calling attention to the current situation in the NHS.
	On Sunday evening, a friend telephoned me from Wiltshire, south of Salisbury. I told her about this debate and she said "You must speak about doctors' out-of-hours working". This is not the first time I have mentioned this, but last time I referred to Yorkshire. My friend told me that her husband, a tetraplegic who had broken his neck, had become ill one night after retiring when his catheter blocked. His wife called the out-of-hours doctor. She sat with her husband all night, waiting. The doctor telephoned at about five am—the doctor was speaking from Birmingham. Is this a service to be proud of?
	This brings me to the need for safe A&E departments that can be reached in a reasonable time. Should people who are severely disabled use an out-of-hours doctor or an A&E department? They really do not know. The Government claim to be bringing care closer to the people, but they are planning to take local A&E and maternity departments further away from them. People do not feel safe without vital services they can reach before it is too late, especially in rural areas. I agree that there should be some centres of excellence for special conditions, but these should be supra-regional hospitals.
	During the summer, I was invited to a south London GP's surgery. The doctors asked me to bring up some matters. I have already sent them to the noble Lord, Lord Warner, but have not yet had a reply, so I take this opportunity to mention them to your Lordships.
	Until recently, a patient was referred by a GP to a consultant specialty in the hospital. Once the patient had been seen in the specialist clinic, if it was deemed that he or she would benefit from a different consultant specialist, the first consultant would simply refer the patient to the second consultant. This was more efficient; it cut down on time and NHS spending. Above all, it was best for the patient. Recently this practice has been stopped. Now, if the first consultant feels that the patient will benefit from another specialty opinion, he or she will refer back to the GP and ask him or her to refer the patient, from scratch, to a different consultant.
	For example, a GP may feel that a patient has a knee pain problem and refers him or her to an orthopaedic consultant. Once at the clinic, the consultant feels that the knee pain is a nerve pain, not a bone or joint problem. He or she refers the patient back to the original GP, with a letter asking the GP to refer the patient to a neurology consultant. This, effectively, is an increase in bureaucracy, red tape and waiting time, leading to more NHS spending. In essence, the GP is billed twice for one patient, as the referral has been duplicated. Above all, the patient suffers from the delay. GPs at the Faccini House surgery at Morden in Surrey feel that this is a ludicrous strategy. Is it to do with targets? Why complicate the life of ill patients? They may have to wait months for a second referral. This is not what the patients expect.
	Last week, the Times reported that Britain would be dangerously reliant on other countries to supply life-saving bird flu vaccinations should a pandemic break out. So far, it is reported that Britain has ordered 3.3 million doses of anti-H5N1 vaccines from two companies, based in Italy and the Czech Republic. A vaccine that would immunise the population cannot be produced until that specific virus strain emerges. Will Britain be able to produce its own vaccine?
	There are so many demands on our health service, but one that does not cost much money and saveslife is the need to enforce hand-washing by doctors and nurses between patients to stop the spread of hospital infections. They must get into this all-important routine. Downgrading of any service will only increase the danger that infections will win in the end.

Lord James of Blackheath: My Lords, many noble Lords have spoken with passion and conviction about individual aspects of the National Health Service which concern them. Those concerns can be addressed only if they are set in the context of a stable, securely financed, well managed and continuing NHS as a body corporate.
	We come to this debate in an almost complete data vacuum, with hardly any information before us by which to assess the current status of the National Health Service. All we have to rely on is a brief document entitled NHS Financial Performance: Quarter 2—2006-07, which is available in the Library. I have arranged—because I think it is very important—for it to be broken out from the NHS website. A lady there can e-mail it directly to noble Lords' computers at any time they wish. I recommend that all noble Lords read it. It is all we have to rely on.
	I read the document in the context of comments which I made during my maiden speech two weeks ago, when I noted that it was claimed that the NHS would have a deficit of £650 million this year. I wanted to see whether that figure would be confirmed today. In fact, the report gives us a choice of three figures for the deficit in the current year. The £650 million figure receives no mention. The report refers instead to a deficit of £883 million, which is said to be the increased figure—it implies that it was the figure quoted on the previous occasion, but it was not. The report then states that the deficit will be only £90 million for the current financial year. It is a remarkable conjuring trick which needs some thought. The figure of£90 million comes after the introduction of the write-back of a contingency of £350 million. We have no idea what that originally stood for, but it has now been thrown in. There is no reference yet to any consequences arising from the intended redundancy programme for 9,000 staff, which was announced earlier this year. The report states quite clearly that only 903 redundancies have been achieved so far—well, only another 8,000 to go. This is of concern, because it is said that the 8,000 redundancies will produce a saving of £250 million to the NHS for the remainder of this year, but we have no idea what, if anything, has come from the first 903 redundancies, which include 187 senior clinical staff. There is no reference, either, to what the cost of the redundancy programme has been or will be.
	How do we get from £90 million to £873 million, which is now claimed to be the deficit? We take the £90 million and add back the £350 million, which comes to £440 million. We put in what we will assume to be the contingency for £250 million of benefit to come from the remaining 8,000 redundanciesto be achieved, which takes us up to a figure of £690 million. I assume that the difference between £690 million and £873 million must be the extra cost of achieving the redundancy programme, although that figure seems a little light.
	However, when we read on, the NHS reportstates that the deficit for the year will not be the£650 million or £873 million which we expected; it will be £1.173 billion. However, no explanation is given of how that figure is reached. We have therefore jumped through three figures in succession without any explanation. This simply will not do. We face a situation where the NHS is clearly playing around with the old problem of contingencies and provisions which magically bounce in and out of the accounts. We need clearer discipline in how these contingencies are applied. Contingencies which are carried over from a previous year are a great evil and an incitement to sloppy managers, who can then write them back into the accounts and pretend that they have achieved positive savings in running levels of overhead. However, it will have done nothing to the running rate of overhead or the funding burden for years to come.
	The Chancellor of the Exchequer should outlaw anything but current-year contingencies straightaway, and he has a very good authority in Jesus Christ on his side for doing so. What else is the parable of the unjust steward or the parable of the talents? That is well worth thinking about. If the Chancellor feels a little uneasy about it, he is in good company.
	As for the rest of the report, we are left in a vacuum. We should have seen a positive benefit of £500 million from this year's redundancy programme. As I said in my maiden speech, I suspect strongly that that has already been conjured away to cover some hitherto unidentified and unadmitted black hole elsewhere in the NHS.
	We are advised by the Office for National Statistics of a 1.3 per cent decline in the National Health Service's productivity in every one of the nine years in which this Government have been in power. That is a cumulative decline of 10 per cent. Through the same period, the funding of the National Health Servicehas risen from £34 billion to a current figure of£72 billion—an increase of 112 per cent—and it is scheduled to rise by another £22 billion, meaning an aggregate increase of £187 billion, in the next two years.
	Those great companies Rover and Railtrack, and even the company which ran the Millennium Dome, all reached the point at which the National Health Service finds itself today. Nobody ever said, "It is time to stop and ask where this really is". It is outrageous that noble Lords present today will not have the opportunity to learn precisely where that deficit is or what the running rate of cash going into the next financial year will be; moreover, they will not be given assurance that it is containable within the present fiscal policy and will not require swingeing new levels of tax to cover it.
	Today's Times states that the Chancellor of the Exchequer is seeking a new task for his "clunking great fist". I have one to suggest to him. He should summon a meeting of the Permanent Secretaries at the Department of Health and the Treasury and put together a small task force to assemble key information, which can be consolidated into a balance sheet and trading account for the NHS, and give us a definitive assessment of the deficit for the year. They should have it done by some time on Sunday afternoon. The Cabinet can then approve a Statement to be made to both Houses of Parliament on Monday morning and lighten our darkness.

Lord Graham of Edmonton: My Lords, it is a great pleasure for someone such as myself to have the opportunity to speak in this important debate. I am very grateful to those colleagues in the House who have spoken and who have demonstrated their eminence and their knowledge of the National Health Service.
	The title of the debate calls attention "to the current situation", which means not only those with expertise and involvement but the recipients of the service. If I speak for anyone it is as a consumer of the National Health Service; I do not pretend to argue for or against on the many valid points that have been made, many of which I respect. But in an organisation that seeks to serve more than 50 million people, it is inevitable that in its organisation and service many people are hurt or aggrieved at the manner in which they are treated. That is the case throughout the country.
	I accept that with all the instances that have been raised, which are blemishes on the record of the NHS, there is probably a case to answer—and the Minister will do his normal competent job in that regard. But I ask noble Lords simply to look at my face. Right by my cheekbone, although noble Lords may not be able to see it very well, is a scar which I have borne since the age of 10, when I lived on Tyneside. My mother sent me to do some shopping. On my way back, half way up a street called Rye Hill, I was set upon by two boys, who said, "Give us what's in that bag". I said, "No", whereupon one of them pulled out a knife and stabbed me. He missed my eye by a fraction of an inch. I was taken to the local doctor, who inserted clips into my face, and I was healed. My mother was trying to keep our house together with a husband who was not only on the dole but on the means test, with five children of whom I was the eldest. Seven of us were living on 37 shillings a week, and she was asked to pay three guineas, which of course she could not afford. So for two years she paid sixpence a week to the doctor to pay off the bill. That was the situation in general at that time.
	At another time, I lay on a hillside in Wales, the subject of friendly fire—having been shot down by a burst of fire from Bren guns—with my intestines in my hands. So I have had experience of the health service before it was the National Health Service.
	Later on in my life, my wife suffered from an inherited disease called myotonic dystrophy. Sadly, as a result of that, she died on Boxing Day less than 12 months ago. Our two sons inherited the disease. So we have a family of a man, his wife and two sons—and I say, "Thank goodness for the National Health Service!" I have a perspective on what it was like before the service existed, which I think many people who criticise the service sadly cannot judge. It is not that they have it too easy, but they have not had the experience to appreciate it.
	I was delighted to hear my noble friend Lord Walton refer to his experiences. I was at a function the other day where a lady was asked where she was from—and she said, "The Royal Victoria". I said, "You mean the infirmary", and she said, "Yes". On Tyneside the RVI was known simply as "the infirmary" rather than the Royal Victoria Infirmary. In every community there is such a place—in Leeds it is St Jimmy's and in my part of London there is Whipps Cross—where the hospital is the saviour for so many people. In my life, I have had two DVDs—

The Countess of Mar: My Lords, that was a very salutary speech. Like other speakers, I am most grateful to the noble Lord, Lord Colwyn, for instigating this debate today.
	I propose to restrict my speech to two subjects, both of which are described by their detractors as figments of patients' imaginations, so I hope that noble Lords will bear with me. As a result they suffer a lack of establishment support and a serious paucity of funding.
	It is only very recently that we have debated the subject of homeopathy. I am raising the subject again today because our homeopathic hospitals are endangered. I do not intend to return to the pros and cons of homeopathy itself. There are five NHS homeopathic hospitals in the UK: in Bristol, Liverpool, London, Tunbridge Wells and Glasgow. All have been part of the NHS since its inception in 1948, though several have existed for over a century.
	These consultant-led services are staffed by fully qualified doctors, nurses and other professionals who have additional training in homeopathy and other complementary therapies such as acupuncture. As is usual in the NHS, patients are referred by their GP or specialist. Homeopathic hospitals are a unique asset to the NHS for several reasons: they offer patients genuine choice of treatment by providing evidence-based, highly professional complementary medicine; although small, they are highly innovative—for instance, acupuncture for pain and complementary cancer care, both now widely available in the NHS, were pioneered by the homeopathic hospitals—and they have made important research contributions, such as researching "effectiveness gaps", conditions for which GPs lack effective treatments, and the outcome and cost-effectiveness of complementary medicine.
	The NHS homeopathic hospitals help many patients who have been failed by other parts of the NHS, including those suffering from "effectiveness gap" conditions, complex chronic problems, or conditions difficult to label and for whom conventional medicine has proved ineffective or has associated serious side effects. The treatments they offer are complementary to, and integrated with, conventional medicine. Their practitioners are qualified health professionals working within the NHS and communicating with NHS colleagues. Surveys consistently show that 70 to 80 per cent of patients report benefit and around 90 per cent are satisfied with their treatment.
	In the past, Governments have reaffirmed their commitment to homeopathy in the NHS, a commitment made originally by Aneurin Bevan. Now, local NHS commissioning and the financial crisis currently affecting the NHS have placed these unique assets at risk. Decisions to refuse funding, which affect patients' ability to choose their treatments, are being made to satisfy short-term financial needs by NHS commissioners with little understanding of the value the hospitals provide. There is concern that commissioners are encouraged in this by a series of high-profile, hostile leaks to the media. These include a leak of a draft of the Smallwood report by the distinguished economist Christopher Smallwood, who highlighted the potential for complementary therapies to provide cost-effective NHS treatment options, which was commissionedby the Prince's Foundation for Integrated Health.The leak appeared on the front page of the Times on 25 August 2005. There was also a letter attacking complementary medicine, which was sent to chief executives of all primary care trusts and leaked on23 May 2006—again, on the front page of the Times.
	While the long-term impact will be the irreversible loss of patient choice, which will leave many patients stranded—in particular, those whom conventional medicine has failed—the amounts of money involved are tiny. West Kent Primary Care Trust wishes to cancel its contract of £160,000 a year with the homeopathic hospital in Tunbridge Wells. This contract accounts for 50 per cent of the patients seen at Tunbridge Wells and its loss would make the service unviable. Local reaction has been very strong: patients have already delivered a 3,000-signature petition to the primary care trust.
	Other homeopathic hospitals are facing similar decisions by PCTs seeking to reduce costs. This is being done in the absence of a cost-benefit analysis. Have the additional costs that will be incurred treating patients elsewhere in the NHS been calculated? Because of the fragmented nature of NHS commissioning arrangements, no one body has oversight of this or of the potential consequences of the irreversible loss of these small, unique units that punch far above their weight in terms of patient care, innovation and research.
	I ask the Minister whether Her Majesty's Government are still as committed to the continued success of all four hospitals in England, and, if they are, what measures Ministers propose to protect them. Additionally, I seek an assurance from the Minister, already given to the House by two of his recent predecessors, that patients who have started a course of treatment paid for by the NHS, and which is clinically effective, will not have their funding withdrawn by reason of cost alone.
	I hope that the Minister has received a copy of the report, published at the end of last month, entitled Inquiry into the Status of CFS/ME andResearch into Causes andTreatment. A group of MPs and Peers, of whom I am one, led by the Minister's honourable friend Dr Ian Gibson MP, read and heard a great deal of evidence from patients, carers, medical practitioners, researchers and others. We found that,
	"there exists a serious disease, which causes much suffering for patients, which may be severe and incapacitating and which causes a multitude of symptoms".
	We were concerned at the lack of interest shown in the UK in the very large number of peer-reviewed and published papers by researchers from other countries which demonstrated the organic nature of the illness. Instead, there has been a consistent bias towards the psychosocial/behavioural model of the illness promoted by Professor Simon Wessely and his colleagues. We noted that, while more than £11 million had been spent on psychosocial research in recent years, no funding at all had been awarded to at least 10 proposals for biomedical research. The recommendations of the Chief Medical Officer in his report on this illness published three years ago seem to have been totally ignored by the MRC. As well as calling for much more research into the biomedical aspects of the illness, we recommended,
	"that this condition be recognised as one which requires an approach as important as heart disease or cancer".
	My main reason for adding this section to my speech today is to draw the Minister's attention to our core findings, but I must also express my concern about a series of documents published on 4 October this year under the heading Occupational Aspects of the Management of CFS: A National Guideline. The details in these documents are truly worrying. In essence, they pre-empt the NICE guidelines, currently being finalised. They emphasise the psychosocial model and appear to imply that patients or employees should not be allowed to lie in bed at home or to avoid activity and should be persuaded to undertake a programme of graded exercise (GET) and cognitive behaviour therapy (CBT). There seems to be no differentiation between individuals who have symptoms of chronic fatigue associated with clinical depression—the noble Lord, Lord Layard, mentioned that—for whom these may be a solution, and those who have CFS/ME as described by the World Health Organisation's ICD-10, G93.3, which the Minister will recognise.
	I know that at least four individuals whose writ appears to run through the Department for Work and Pensions and the MoD as well as the Department of Health, and who seem to have a consistent interest in preventing the acceptance of anything but the "it's all in your mind" model, have been involved in the production of the publications. May I ask the Minister how many doctors or other advisers who accept CFS/ME as a biomedical illness were involved, how much did the exercise cost, and what will be the standing of the documents once the NICE guidelines have been published?

Baroness Neuberger: My Lords, I, too, thank the noble Lord, Lord Colwyn, for introducing the debate today. Like many other noble Lords in the Chamber, I would like to address an enormous number of issues, but I will reduce my remarks to make my speech shorter in a very long debate. People will be very pleased to hear that. I have to declare some interests. I am an honorary fellow of the Royal College of Physicians, the Royal College of General Practitioners and the Royal College of Psychiatrists, an honorary fellow of the Faculty of Public Health, and an adviser to the Sainsbury Centre for Mental Health.
	I really want to address the emphasis that the Prime Minister and others have put on the necessity of keeping up the pace of change—of reform—in the NHS, even while accepting that, to some extent,the Department of Health in particular and the Government in general have not made a very good fist of getting people to understand why that is so vital. In the Queen's Speech we heard the bald statement about keeping on with the reform of the NHS, without any clear statement of what that direction might be. Now two NHS tsars, Doctor Roger Boyle and Professor Sir George Alberti, tell us that emergency provision and some cardiac services are unsafe as configured at present and that they need to be centralised for greater expertise and safety reasons. They are very likely right, yet at a time when deficits are hurting and much of the public, let alone front-line NHS staff, believe that this has more to do with money than with better services, it is rather difficult to make the case.
	As the noble Lord, Lord Colwyn, said at the beginning, with accident and emergency and maternity services being taken further away, people do not trust the Government with our much-loved NHS. I say to the noble Lord, Lord Graham—who rather took the economist Rudolf Klein's view that the NHS is perhaps a church rather than a garage, though the right reverend Prelate and I might disagree with that—that people love and respect the NHS, but that does not mean that we always think it has got it right. The noble Lord, Lord Parekh, pointed out that perhaps the NHS needed to listen harder to some of its patients when removing services from their immediate locality.
	The noble Baroness, Lady Masham, raised the issue of getting help in the immediate locality when you need it in the middle of the night. My noble friend Lord Rodgers of Quarry Bank raised the very important issue of stroke services, not for the first time. We know that stroke is a huge problem. Despite the Government's assurances and reports going back over 10 years—when I first arrived as chief executive of the King's Fund in 1997 there was already an NAO/King's Fund report on what was needed in stroke services—despite everything we have said and guidance for treatment of older people and people with stroke, such an approach has still not really been implemented. Yet it is an agreed, evidence-based approach. When does the Minister think that it will be well integrated into the service?
	Equally, the noble Lord, Lord Layard, raised the issue, as he has powerfully done for some time now, of evidence-based psychological therapy. GPs want it and the evidence supports it, as does the Royal College of Psychiatrists, yet many people with quite severe mental illnesses get therapy on the cheap. If you go to the United States, you can see services in cities such as Philadelphia that are provided free to homeless people. They would not tolerate the level of service in psychological therapies that we are still offering our patients. The noble Lord, Lord Layard, is quite right to say that in such mental health services everyone who suffers should be treated as we would like to be treated. We should get rid of the poor law mentality.
	Although I have to declare an interest because of the Sainsbury centre, I would like to commend what the noble Baroness, Lady Murphy, said about deficits. There are major deficits, and the budgets of two-thirds of mental health trusts have been raided, although they kept within budget, to plug the deficits in the acute sector. This is occurring at a time when we are concerned about the kind of services provided in mental health.
	As a former NHS trust chairman, one of my real concerns is that the pace of reform is such that people do not have time to let change bed in before there is yet more change. We all accept that there is much more money in the system, yet we have record deficits. We all accept that the architecture brought in by the Government—NICE and the Healthcare Commission—is broadly sensible and to be welcomed, yet there are questions of detail around NICE. With nurses unemployed, older patients malnourished in our hospitals because nurses say they do not have time to feed them, and doctors complaining of the changes in medical education and what happens at the end of medical training, and with serious concerns about privacy in the data system which is being rolled out, as the noble Earl, Lord Northesk, pointed out, it seems that there is plenty to sort out. When it comes to dignity campaigns and dignity nurses in every hospital for older people, one can only say that perhaps it is a good thing that that rather crazy initiative has been quietly parked. It cannot be one nurse's responsibility to give dignity to older patients; it has to be everyone's concern.
	The founders of the NHS recognised the importance of underpinning the delivery of health services with a commitment to research and education, and successive Secretaries of State for Health have reaffirmed that commitment. The tripartite mission of research, education and service delivery has put our university hospitals at the forefront of innovative and high-quality patient care, even though the money at their disposal is as nothing compared with what they might have if they were in the United States. The £3 billion invested annually by the Government and medical research charities achieves huge success, as the noble Lord, Lord Crisp, said, when compared with the £2 billion invested simply in the greater Boston area of the United States. British doctors and scientists are exceptionally creative and effective, which we have to put down to the high quality of education and training they received early in their career. Yet current initiatives are undoubtedly endangering this precious base. Some 25,000 students now enter our universities to study nursing, 8,000 to study medicine and a further 1,000 to study dentistry. That is hugely better than 10 years ago but essential due to our ageing workforce.
	The funds to support education and training of the healthcare workforce have traditionally been ring-fenced, as others have said. The noble Lord, Lord Walton, made a very strong case on the point. This year, for the first time, the funds have been delegated to the strategic health authorities to be used locally as deemed fit. Although it is hardly surprising that the greatest cuts in those education and training budgets are being experienced in SHAs with the greatest deficits—as the noble Baroness, Lady Murphy, said—it is hugely short-sighted. It seems illogical, to put it mildly, that the Government are introducing the new system of payment by results, with their national tariff for NHS procedures, but fail to have a national tariff for education and training.
	Cuts in education and training are being imposed without consultation around the country. There is no monitoring of SHAs' performance on education and the quality is undoubtedly suffering. That does not make any more sense than to have newly qualified nurses unemployed and specialist nurse roles threatened or asked to be generalist, yet to have a considerable number of agency staff working in the system. Transparency is a mantra often repeated by the Government, yet there is no transparency in the SHAs and education budgets. Surely, given the original investment, a national framework needs to be agreed so that we can protect the next generation of healthcare workers.
	I want to move on to what the right reverend Prelate the Bishop of Worcester said about the financial regime, which is so draconian that all round us we are seeing eccentric cuts including, as he said, to chaplains in his local patch and threats to chaplains in other areas of the NHS. There seems to be no explanation for those cuts and no one seems to know how many are the result of moneys owed to PFI companies. A steady stream of money is going to those companies, as the noble Lord, Lord Selsdon, said. It looks like a debt, as the right reverend Prelate said, and it feels like a debt. Is it a debt? Is the noble Lord, Lord James of Blackheath, right in asking for clarity in the figures?
	The right reverend Prelate was concerned also about the heart of the service. Noble Lords on all sides of the House love and respect the NHS. I very much hope that the Minister will respond to some of the issues raised by all noble Lords that demonstrate our concerns about the heart of the service. If the heart of the service does not care for the most vulnerable, and people do not think about the values of the service—as happened five years ago in the NHS Plan, which has sadly been somewhat abandoned—then the staff will not feel comfortable and patients will feel even more uncomfortable. I hope that the Minister can say something about that.

Earl Howe: My Lords, my noble friend Lord Colwyn is liable to be asked rather often from now on to lead our health debates in this Chamber because his speech today was quite masterly. When it comes to dentistry, we always expect him to lead the way for us, but we have been reminded of how well he can do so across the full canvas of current health issues. I congratulate him most warmly.
	As we look at the NHS today we see a seemingly inexplicable paradox: more money going in than ever before, yet services under very intense financial pressure. As my noble friend said so clearly, that pressure is manifesting itself in visible cuts, and the cuts that we are seeing are not in the least peripheral. They are in core areas. Education and training budgets are being raided to offset deficits in service provision. Nurse posts are being frozen or cut, not because of staffing requirements but because cash cannot be found. Almost half of newly qualified nurses have not found jobs this year. In physiotherapy, the percentage is much higher.
	Maternity units, both midwife-led and consultant-led, are being closed down or are under threat of closure. This is happening not on the basis of service effectiveness or what patients want but largely because of budget cuts. So much for patient choice. In the very topical area of mental health, more than half of mental health trusts, as we have heard, have seen money diverted away to prop up the local NHS economy, with the result that in many areas wards are being closed or are under threat of closure. The Community Hospitals Association says that 81 community hospitals are under threat of cuts or closure. Elsewhere in the community, far from there being more midwives, health visitors and district nurses, the numbers have actually fallen.
	The latest issue in the headlines is A&E departments, 29 of which are under threat of closure. We all understand that service configurations cannot be set permanently in aspic, but instead of being up-front about the real reasons for making changes, the Government are talking about improved patient care. In many if not most cases, there are two real reasons: the European working time directive and shortage of money. Matters of that kind are of absolutely critical importance for saving lives and should be decided mainly on a balance of safety and access. But the actual evidence base for what constitutes the right balance is nowhere to be seen. We are being fed a bogus rationale, and that is deplorable.
	The Government are fond of saying that, with all the extra money being channelled into the health service, budgetary pressures are simply the result of poor decisions at local level. I do not buy that line, and perhaps I may tell the Minister why. The reasons for the present financial pressures are many, but there are three that have nothing whatever to do with local decision-making and everything to do with decisions by Ministers. They are: the deliberate top-slicing of PCT budgets by Whitehall, which effectively removes much of the growth money from PCTs; NHS reorganisation; and woefully disjointed implementation of government policy.
	The top-slicing of budgets brings us back to old-fashioned brokerage, only this time it is being applied indiscriminately. Where all this money is going to be applied, we shall no doubt hear in due course. But an equally big, if not bigger, cause of difficulty is the adverse effect of NHS reorganisation. Frankly, I have lost track of how many reorganisations of the NHS there have been since Labour came to office, but Ministers' passion for restructuring the health service has been hugely expensive. This year, the redundancy bill alone will be anything up to £400 million. It has also been expensive in another sense in that it has engendered a climate of seemingly continual upheaval and change. The main casualty of that has been something supremely precious: staff morale. One PCT chair giving evidence in another place to the Health Select Committee inquiry into primary care trusts said that some of the staff in his area have had five different employer names on their payslips in less than 10 years. The combination of uncertainty, constant upheaval and poorly managed announcements has made committed PCT staff feel unsettled and undervalued.
	Nowhere, perhaps, has reorganisation been more disruptive than in public health. The number of full-time equivalent doctors in public health has gone down by 19 per cent over the past few years. Yet this year, four out of 13 medical deanery regions have cancelled their spending on public health training altogether. The Chief Medical Officer has spoken of,
	"a consistent story of poor morale, declining numbers and inadequate recruitment and budgets being raided to solve financial deficits in the acute sector".
	The reorganisation of PCTs has halved the number of posts for directors of public health. A recent survey showed that one in three public health doctors is considering leaving the field because they are worried about the future and demoralised. The danger is that we are losing the very people whom we need to provide leadership and experience in this vital area of long-term preventive work. We cannot afford that.
	The third factor that I wish to raise is the disjointed implementation of government policy. The GP contract, though beneficial in making general practice more attractive to doctors, left it to PCTs to ensure adequate out-of-hours cover. That abdication inthe contract, we now learn, has cost no less than£346 million a year, more than three times what the department budgeted for. It is no wonder that PCTs are struggling to find that sort of money; but it is hardly their fault. Hospitals, locked into PFI contracts, have found that, under payment by results, the goalposts have been moved: their income is now more volatile and the level of the tariff is not realistic in relation to their running costs. It is a truly classic example of one piece of government policy cutting across another. Then there is the unco-ordinated way in which market mechanisms have been introduced to the NHS, and especially the destabilising effect of payment by results.
	Payment by results was always going to be an extraordinarily difficult system to embed into the health service. We could have guessed that simply from the problems experienced in other countries which have tried it. But, instead of learning from the experience of other countries, we have reinvented our own version of the wheel and have chosen to do it in a rather crude way. As an indicator of costs, the tariff is a very broad-brush sort of measure. It is essentially an average of a wide range of treatments and case-mixes, resulting in considerable cross-subsidy between different procedures. That may be all right where hospital providers have security of income, but it is highly vulnerable to competitive intervention from providers who choose to focus on routine, high-volume cases or who can deliver treatment at a lower cost than the tariff assumes. We see exactly that kind of destabilising competition going on now.
	One of the key features of payment by results is that it is a powerful instrument for incentivising activity. It is literally a market-making tool. So, if you are going to let it loose, you need to apply it within an environment where costs are calculated with some precision, where there are relatively strong purchasers and where there is effective competition among providers.
	However, that is not what the NHS has, and, in many cases, the result is severe financial stress at PCT level. Payment by results has not been introduced in parallel with an effective means of managing demand. That is not the NHS's fault; it is the result of poor planning at the centre. One day, practice-based commissioning may provide the necessary counterweight on the purchaser side, but it has not been rolled out properly or soon enough.
	The NHS continues to provide dedicated and often very fine care and treatment, despite its financial stresses, but we really need to see those stresses in their right context. The Government are entitled to take credit for the improvements which there have undoubtedly been, but a little frankness and contrition occasionally would not go amiss.

Lord Warner: My Lords, this has been a wide-ranging debate. I shall not be able to respond to all the points but I guarantee to write to people because some of those points were detailed and require, and deserve, a longer explanation than I have time for.
	I am grateful to the noble Lord, Lord Colwyn, for this opportunity to discuss the current situation in the NHS because it provides me with an opportunity to remind noble Lords about the real situation and achievements in the NHS under this Government. It also gives me an opportunity to talk a little about our vision of the future and to counter some of the wilder accusations that are currently circulating, a few of which we have heard today.
	I reassure the noble Lord, Lord Selsdon, that I shall not be giving him a story of perpetual sunshine, which his political leader in the other place occasionally indulges in; and I assure him and the noble Earl, Lord Howe, that I accept that sometimes it rains in the NHS. But—and it is a "but"—I am pleased to have the opportunity to remind people about the past. I believe that one of the best predictors of future behaviour is past behaviour. I do not want to dwell on this too long but I have to remind people, painful though it may be, of the legacy that we inherited, and my noble friend Lord Graham has already reminded us of the situation before the NHS came into being.
	When this Government came to office in 1997, the NHS had a largely Victorian infrastructure. According to the King's Fund, in 1997, the average age of NHS buildings was older than the NHS itself. There were staff shortages: 37 per cent fewer doctors; 27 per cent fewer nurses; 36 per cent fewer allied health professionals; and 17 per cent fewer GPs; and the previous Government did not even bother to count separately healthcare scientists. Two dental schools had been closed in 1992 in London and Edinburgh, causing a loss of 80 training places. There was a history of staged pay awards: eight for doctors and five for nurses and midwives. Perhaps most interestingly—this will be of particular interest to the noble Lord, Lord James, in his thirst for knowledge about financial deficits—the NHS financial deficit in 1996-97 was £459 million, which was 1.5 per cent of the total NHS allocation, compared with 0.7 per cent of the total NHS allocation for the deficit in 2005-06. I do not want to dwell too much on this but that is the context that we inherited, and it has an impact on the current situation.
	I accept that there is still more to do if we are to have a 21st-century healthcare system. But, since 1997, we have seen far-reaching improvements, which many people have acknowledged today. There are now 404,000 extra staff: 85,000 more nurses; 122,000 more doctors; 61,000 more allied health professionals; and over 16,000 more radiographers and physiotherapists. Those are large increases by any stretch of the imagination. There are nearly 4,700 more GPs than there were in the past. Part of the reason why we have more GPs and other staff is that we pay them better, and I shall come to that a little later.
	We are investing in more training places to secure future staffing levels: 10,600 more medical students have entered training since 1997; a major expansion of dental training is under way; and over 10,000 more nurses and midwives are being trained than in 1996-97. I accept that the money being spent on training in the current year has plateaued off, but it is doing so following huge growth, and the money that was allocated to SHAs in the current year for SIFT and other payments is roughly the same amount as was issued in the previous year. Of course, we have given SHAs authority to take account of local priorities in spending the money but, listening to some of the discussions, one would not have recognised the level of the increase in the money for education and training that has been put into the system.
	We have literally hundreds more hospitals, GP surgeries and health centres, thanks in part to the private finance initiative; and there is no evidence that the PFI initiative has caused a huge number of deficits. It is worth remembering that all the trusts that entered into a PFI agreement were asked to test against rigorous guidelines the affordability of the project that they wanted to go forward with. All those projects were subject, as are LIFT and other projects, to Her Majesty's Treasury's value-for-money scrutiny. So we have a rigorous system in place.
	We have improved services and access to those services. We have cut waiting lists—260,000 fewer people are waiting compared with six years ago; we have improved access to A&E departments and GPs; and there are improving mortality rates. For example, deaths from cancer in the under-75s fell by nearly16 per cent between 1997 and 2004. That is not just a statistic; it is 50,000 lives saved—50,000 people are alive when they would not otherwise have been. And we are on track to reduce deaths from heart disease by 40 per cent—or 150,000 lives—by 2010.
	We have begun the process of implementing a national programme for IT. It is simply not true, as the noble Earl, Lord Northesk, suggested, that we have had little progress to date. I cannot go through all of it but, for example, more than 90 million digital images are now stored, with people using the picture archive and communication system packs. We are getting close to the point where 50 per cent of patients in the NHS will have their images on that picture-archiving system, instead of X-ray films. I shall give the noble Lord all the details, and will circulate them to all other noble Lords.
	My noble friend Lord Layard rightly paid tribute to the improvements that have taken place in mental health. There have been huge improvements, and I pay tribute to the work that he has done on talking therapies. We certainly want to continue working closely with him on them. Since we published the National Service Framework for Mental Health in 1999, planned spending on mental health hasgone up by more than 25 per cent in real terms—nearly £1 billion a year.
	Let me reassure my noble friend that there has been a huge shift in services from in-patient services to the community, with new roles for staff and new, more individual services for service users. For example, in 2005-06, almost 84,000 home treatment episodes took place for people who would otherwise have required in-patient admission. We have expanded community services for people with mental illness. One of the reasons why we need new mental health legislation is because the 1983 Act is out of date.
	All these improvements have been delivered thanks to the dedication and commitment of 1.3 million NHS staff as well as the Government's record levels of investment. I share the views of other noble Lords that these improvements are down to those staff and their hard work day in, day out. But their job is made easier by the fact that there are a lot more of them to do it than there were 10 years ago.
	Of course, everything is not perfect, and probably never will be. But we have to consider what patients who experience the NHS have been telling us. They tell a different story from some of the stuff in the media. According to the most recent findings of the Healthcare Commission's—not the Government's—national patient survey programme, 92 per cent of adult in-patients rated their care as good or better, as did 94 per cent of adult out-patients and 88 per cent of those who had experienced A&E. That survey was carried out this year. In primary care, 97 per cent of patients said that the main reason they had for visiting their practice was dealt with to their satisfaction. When asked about their experiences, NHS users report a totally different NHS from that which we read about day in, day out, in many of our media outlets.
	I am proud of what the NHS has already achieved in the face of fundamental and, sometimes, painful change. I acknowledge that change is difficult; it is tough; it is hard going. But more is inevitable, not just because the Government are dreaming it up, but because we have to make continuing improvements in health and social care.
	The noble Lord, Lord Crisp, drew attention to the experience overseas. All advanced countries with healthcare and social care systems experience the challenges that we are experiencing. There is no escaping those challenges, and I shall mention three in particular. I can understand why the right reverend Prelate and others want us to walk more slowly. I suggest that the challenges that I shall describe make it difficult for us to do so.
	First, I refer to demographics. Our population is getting older and more of us are living with illness. By 2025 there will be two-thirds more over-85s. More and more people are living with long-term conditions, and more and more profoundly disabled babies are living to adulthood. This means a massive increase in demand on health and social services.
	Our 21st-century lifestyles do not always help. By 2010 we expect almost 13 million adults to be clinically obese, and we are already seeing the associated rise in strokes, heart attacks and type 2 diabetes. The second challenge is that we are experiencing a revolution in medical technology. The noble Lord, Lord Crisp, rightly drew attention to the good track record in this country in biomedical science. Every week, new drugs and treatments are being developed. In a few years' time, doctors will be able to use drugs that are tailored to the unique DNA of an individual patient. It is quite clear from a casual reading of the media that people want those drugs made available to them, especially when they deal with a life-threatening situation. These advances are, of course, to be celebrated. However, there is no escaping the impact they will have on the cost of treatment.
	Finally, there is the inescapable fact that the expectations of our fellow citizens continue to rise—as do our own—as more opportunities to help people present themselves. Waiting times are shorter, but they are not short enough. People also want the NHS to provide them with the same level of control, choice and convenience that they expect from other services. We all expect that as individuals, so why should not everybody else? That presents a challenge. It is also a challenge to ensure that the groups to which my noble friend Lady Howells rightly referred share in those benefits. We must tackle health inequalities even more vigorously.
	People want to be treated closer to home; they have made that clear. They want less invasive procedures. If most of us are confronted with a less invasive therapy or surgery, we will take the less invasive procedure. But that has consequences: consequences for the staff providing the treatment, consequences for the places where the treatment is provided and consequences for at least transitional costs. The national Institute for Healthcare Improvement report published today makes it clear that providing care closer to home is undoubtedly possible. We want to make sure that the opportunities to do this are grasped. We want a health service, not just a sickness service, in this country. We want to rebalance the system towards ill health prevention and good health promotion. Our future-oriented White Paper, Our Health, Our Care, Our Say, published in January, set out a clear direction of travel. We are already making good progress in many areas. I do not have time to dwell on all of them, but something for which the Government deserve great credit is the Health Act, which is nowin place, and we are committed to implementing smoke-free legislation in the summer of next year. Tobacco does kill, and we have taken action to reduce the impact of that on a wide range of people, including some of the poorest in our society.
	Sexual health is a challenge, but it is one of the top six priorities for the NHS in 2006. That is why we are investing more money in modernising sexual health clinics and services. We will be debating some of these issues in more detail next week, so I shall not spend too much time on them now.
	A number of noble Lords talked about some of the issues relating to reconfiguration of services. Technological advances pose a challenge, but they represent a golden opportunity to make services safer and produce much better outcomes for patients. They often represent an opportunity to improve efficiency. I recognise that the transition for that, to which a number of noble Lords referred, causes difficulties for those who have to change the way in which they work, or where they work. It also means reskilling programmes and often means a transition set of costs. No Government will find it easy to make cashable savings in acute hospitals as service configurations change. This is a tough challenge for any Government in any healthcare system.
	Monday of this week saw the launch of the personal reports of Professor Sir George Alberti and Professor Roger Boyle, the national clinical directors respectively for emergency access and heart disease. Both of them are eminent clinicians with the best interests of patients paramount in their thinking.
	Roger Boyle, in his Mending Hearts and Brains—a graphic title—showed us the evidence that it is safer to bypass the nearest local hospitals to make sure that a patient gets specialist treatment in the right setting from doctors and nurses with the right skills to save lives. A patient taken directly to a specialist angioplasty centre is likely to recover from a heart attack or stroke more quickly and without continuing debilitating illness. The way forward for many of the concerns about stroke that the noble Lord, Lord Rodgers of Quarry Bank, rightly drew attention to, is described by Roger Boyle in that document. I recognise that the glass needs to be fuller and that we must work on stroke services.
	When the NHS reorganises, it does so primarily for the benefit of patients. Despite what our critics might say, reconfiguration is about providing better, safer and more convenient care. As the noble Baroness, Lady Murphy, said, transformation is sometimes accelerated by the need to look at how the money is spent. In producing their personal reports, the national clinical directors have highlighted how more patients are already being treated outside hospital. That trend will undoubtedly continue.
	Your Lordships will be pleased to know that I shall not dwell on how much we have spent on the NHS, but expenditure improvements have been huge. It is not unreasonable to expect that, within that rising growth, there should be good financial management of those resources. There is no particular reason why some of that money could not have been better spent. We must concentrate on those parts of the NHS with serious financial deficits, but we must keep that in proportion. At the end of quarter 2 of 2006-07, 50 per cent of the NHS gross deficit—not the net deficit—is concentrated in only 6 per cent of organisations.
	I recognise that some parts of the NHS have reacted to years of staff shortages and underfunding by recruiting faster than was perhaps necessary. For example, we set several targets for increasing the number of nurses which, taken cumulatively, would have given a staffing level of 385,000 by 2008. This level of growth was achieved in 2003. We now understand that we are seeing a degree of accelerated recruitment. Of course, that will cause some trusts difficulty. Overall, however, I would sooner be in that position than the one the NHS faced in 1997.
	I do not have time to continue far along this path, but the noble Lord, Lord James, was concerned about the absence of data. I commend to him the annual report of the Healthcare Commission on the state of the NHS and the performance of individual trusts, produced each year, which gives a lot of information about financial management and quality in those trusts. I also commend the six-monthly reports of the NHS Chief Executive—begun under the noble Lord, Lord Crisp—which give a wealth of data on how well the NHS is running. They give a lot more detail on how things are improving than the report which the noble Lord served up to the previous leader of the Conservative Party for the last election.
	In conclusion, whichever way you look at it, the net outcome of our investment in the NHS and the changes already made are a good deal for patients, providing a good base for the future. We have preserved the founding principles of the NHS: the values of a publicly funded service, free to all, equally, at the point of need. We have safeguarded that for future generations.

Lord Colwyn: My Lords, only a few seconds remain in this short debate. I thank all noble Lords who have taken part, and recognise that their contributions have demonstrated a wide range of expertise and experience.
	The Minister did not mention the dental treadmill, which is of particular importance to me. I hope that he will note the plea of the right reverend Prelate the Bishop of Worcester for targets for walking slowly and gentle, caring involvement. Perhaps the right reverend Prelate would consider joining the dental negotiating body for targets and recognition; that sort of advice is exactly what is needed to remove the treadmill and encourage dentists to talk to their patients without having to earn points for invasive treatment.
	The NHS is a wide-ranging subject. I know it will be debated on many occasions in future. In the mean time, I beg leave to withdraw the Motion for Papers.

Lord Bruce-Lockhart: rose to call attention to the funding of local authority adult social services and the consequences for the rising numbers of elderly people; and to move for Papers.
	My Lords, I am grateful for the opportunity to review the funding of local authority social services today, especially in the company of so many noble Lords with great experience in these matters. I declare an interest as chairman of the Local Government Association, although I speak for myself. I shall address three questions. First, is there clarity and consensus about demographic change? Secondly, what kind of care services do we need for the decade ahead? Thirdly, what is the funding requirement to respond to demographic change and change in service demand?
	It has been said that you can judge a society by the way it treats and cares for its elderly people. That was never more so than it is today. I was pleased to see that the Treasury's Comprehensive Spending Review 2007 set out just five factors of change and that one of them was rightly the challenge of demographic and social change. Rising to the challenge of demographic change will certainly be one of the "key tests" in judging CSR 2007.
	The over-85s require the most urgent attention and the most intensive care. According to the Government's actuaries, in 2005 there were 1.2 million over-85s and by 2050 there will be 4 million. For the first time, there are more people in England over 60 than under 16. In the Comprehensive Spending Review challenges report last month, the Chancellor focused only on the next 10 years, reporting a forecast 38 per cent increase in the number of over-85s. His report also drew attention to what he called the "baby boomers"—the increased birth rate in and after the Second World War—which, coupled with increasing life expectancy, now brings a dramatic increase in the number of over-65s. There is clear recognition of dramatic demographic change but, I am afraid, a failure to act on it.
	In considering a changing service, we need to respond not only to the demographic change in numbers. Help the Aged, Age Concern, the King's Fund, numerous charities and local authorities are also reporting a sharp increase in mental, learning and physical disability in old age. We must respond to this, too. At the same time, local authority adult social care budgets are also responsible for the 16-to-65 age group. In this group, we see that medical advances, coupled with better health and social care, mean that children with the most severe learning and physical disabilities are often living into middle age. Indeed, the director of social services in my own county of Kent reports that this financial demand is now even greater than the escalating demand from changing demography. Those vulnerable young people require and deserve intensive, high-quality care.
	In 1991, the Government introduced a Bill on community care that allowed elderly people to receive care in their own homes for the first time. That radical reform brought new independence to the elderly and has been, and must be, built on so that independence is the central principle of a changing service. Last week, the Commission for Social Care Inspection reported improvements in social care by local authorities. It is clear that community health and social care services must be designed around the needs and wishes of elderly people. Social care services must be personalised, offer choice, focus on early intervention and prevention, bring a higher quality of life for elderly people, deliver care with kindness and compassion, and give time. They must also value and care for the many carers who do invaluable work. At the same time, we need greater innovation and stronger partnerships between social care and the health service and stronger working with, and a stronger role for, the voluntary sector.
	The Wanless commission pointed to the need for a funding increase of some £20 billion for care of the elderly over the next 25 years, an increase of almost£l billion a year, yet we have had no response from the Government. However, the situation for elderly people and the facts from the Government, local authorities and many charities and voluntary groups are entirely clear. The Treasury forecast that in the next decadethe number of people aged over 85 would increase by 3.8 per cent a year. The Local Government Association's autumn statement showed a 6 per cent increase in the number of weeks of care commissioned by local authorities last year alone, but, to pay for that increase, half the social service authorities had an increase in government grant of 2 per cent or less this year. While the NHS has had a 90 per cent increase in real-terms funding over the past decade, local government services, including social care, have had an increase of just14 per cent.
	A year ago, social service directors reported that they started this year with a black hole from 2005-06, when they spent 13 per cent—£1.8 billion—more on adult social care than the Government estimated for funding. On top of that, there are numerous other factors, including cost pressures, the reduction in grant under the Supporting People programme and the new and additional costs from direct payments, to which a recent Audit Commission report drew attention. As a result of the new demand, the absence of any new funding or action from the Government, and because council tax payers cannot pay more, half the social service authorities in the country are reporting that they are raising eligibility criteria and so rationing care for the elderly. In a civilised society, that is unacceptable.
	When we consider funding, the relationship between local authorities and the health service is the central issue. On the one hand, local authorities have been working in close partnership with the health authorities. A number of social care departments, working with their health authorities, set themselves a target of reducing hospital admissions for people over 75 by20 per cent. The majority of those 10 authorities achieved that target, but through additional cost to the local authority. However, it brought financial benefit to the health authority and real benefit to elderly people. That is encouraging, but, on the other hand, due to the current cost pressures within the NHS, many local authorities are reporting cost shunting by the health service. In my own local authority, the East Kent Hospitals NHS Trust closed 180 beds this year, which has resulted in earlier discharges and the need for higher and more intensive levels of social care. It also brought reductions in primary care services, which the health service would not wish for. However, cuts are being made in respect of district nursing, community matrons, community physiotherapists and the NHS equipment provided to residential homes.
	I am pleased to say that this issue is recognised across the board, not least in my own party. Just last month, my colleague in another place the right honourable David Cameron identified,
	"the artificial and damaging barrier between the NHS and social care services".
	Organisations that break down that barrier do so against the odds. To give an example from my local authority, in the case of NHS continuing care, it is estimated that 24 per cent of those in nursing homes in Kent have care needs that should be the responsibility of the NHS. We urge the Government to develop a test of eligibility with clear criteria that are understood by all so that we can resolve that issue.
	The White Paper on health, published last month, calls for,
	"a shift in the centre of gravity of spending. We want our hospitals to excel at the services only they can provide, while more services and support are brought closer to where people need it most".
	It is right that services and support should be brought to community social care and community health care, but where are the action and funding to support that?
	None of these issues is easy, but we urgently need solutions. It is clear that local authorities and private and voluntary providers of care services for the elderly must rise to the challenges of changing need and increasing demand. However, it is also vital that we have a resolution to the immediate funding crisis in the provision of care services for the elderly and for vulnerable adults. We also need a clear statement from the Chancellor about his intentions for CSR07 and how funding will be provided to enable us to rise to the demographic and social challenges of the next decade that are so important for any civilised society. I beg to move for Papers.

Baroness Pitkeathley: My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for introducing this important debate. He is uniquely well placed to do so. Last night, with two colleagues, I hosted a party to celebrate the 100 years that we had spent in social care. I hasten to add that it was 100 years between us, not each, although sometimes it feels as though I have been doing it for 100 years. I reflected on some of the terminology we use, how it has changed over the years and especially how we refer to people who access the services provided by local authorities. They went from being called the "applicant", to the "client", to the "care recipient", to the "user" and now the "customer". The changes in terminology reflect the changes in the way that services are provided. We should not forget that "social care" itself is a relatively new term. We used to call the services provided by local authorities in people's homes, predominantly to older people, "domiciliary care" or "care in the community".
	I was one of the advisers to the Griffiths review of community care, which was published in 1988. It was one of the most significant documents in the development of this type of care, and, as far as I recall, the term "social care" was not used at all. It has come to be used as a sort of catch-all to identify any care which is not healthcare and primarily the care which is the responsibility of the local authority.
	The Griffiths review was extremely significant, some noble Lords will remember, for two main reasons. First, it was very strong on the principle that care should be organised as near as possible to the care recipient and his or her family, and that meant by the local authority. That seems perfectly normal to us now, but at the time, when local authorities were so unpopular and so underrated by the then Government, it was pretty well a revolutionary idea. I remind your Lordships that the report was virtually suppressed for more than a year before the Government finally and reluctantly took Sir Roy Griffiths's advice.
	The second reason the Griffiths report was so significant, at least from my point of view, is that it was the first time that the contribution of family carers to the provision of what we now call social care was truly acknowledged. All these years on, I am still convinced that Sir Roy Griffiths was right. Overall, the record of local authorities in delivering or overseeing the delivery of social care is a fine one, as the latest statistics show. They have not only proved their value and commitment to supporting the care recipients but they have also been pioneers in the recognition and support of carers, aided and encouraged of course by the pioneering work of organisations such as Carers UK and by three separate Acts of Parliament.
	Although the number of carers has remained static since records began in 1985, the number of carers providing substantial care—more than 20 hours per week—has increased from 1.5 million in 1990 to1.9 million in 2001, the latest year for which we have proper statistics. The value of carers' support has increased from £34 billion to £57 billion.
	Carers UK's helpline increasingly hears from carers whose breaks packages are being cut, where day centres are being closed and domiciliary care packages are being cut back. Local authorities are telling carers that they are short of funds and many are not reassessing carers—in direct breach of the law.
	The consequences for carers are dire. That way of working is also very short-sighted. If insufficient care is provided, people are likely to give up paid work at a time when they most need to build up pensions and work towards retirement. As a society we simply cannot tolerate that. We must therefore ensure that services for carers are provided in a way that enables them to combine paid work with caring. That means providing support for carers before a crisis point is reached.
	We must be mindful of resource problems of local authorities, as the noble Lord reminded us, but the current withdrawal of early intervention and preventive services is very short-sighted. To intervene earlier and give care and support is not only cheaper at the time, but the carers also are likely to keep caring longer. That is why the White Paper Our Health, Our Care, Our Say, which focuses on supporting local communities to make a strategic shift towards prevention, is so welcome. The key initiatives, including the partnerships for older people projects, popularly known as POPPs—I understand that several more have been announced today—are very important. It is particularly important to help carers. I am glad that today's announcement of another 10 projects emphasises the needs of carers.
	If services are to be provided satisfactorily for carers, the carers must be, both in rhetoric and reality, equal partners. I am very glad that so much progress has been made towards including carers in that regard, including extending and updating the 1999 strategy for carers. All these initiatives must be carefully monitored at local and national level.
	In the limited time I have left to speak, I want to mention two more things. The first is the third sector provision and co-operation with local authorities. Can the Minister tell the House about the announcements made yesterday, in the action plan for third sector involvement in public services, about skills and systems for commissioning from the third sector? How will they be followed through? I do not need to remind your Lordships that third sector providers are hugely important in providing effective and user-focused services. However, local authority commissioners are still too likely to commission, as they have always done, without regard for the skills and experience of the third sector.
	Finally, although the staff ratings of local authorities are improving, there is still not enough joined-up working across health and social care. Can the Minister remind us about the progress that is being made on the care services improvement partnership and the other initiatives with social services announced in the autumn?

Lord Low of Dalston: My Lords, I very much welcome this debate, as it gives me an opportunity to expand on an all too brief reference to social care that I made in my maiden speech a couple of weeks ago. It also enables me to say something about independent living for disabled people, which is the subject of the Bill tabled by the noble Lord, Lord Ashley, which returns to the House on 15 December. I very much regret that I will be unable to be present to support his Bill.
	The Disability Rights Commission speaks of adult social care, especially for disabled people, as being in crisis. In a way, that is true, in that social services are largely geared to crisis management. The noble Lord, Lord Bruce-Lockhart, spoke of the crisis. To a large extent, only those whose needs are judged to be critical or substantial receive service. Most often, it is the needs of children, which hit the headlines, that are prioritised. There is nothing wrong with meeting the needs of children, but adults have needs which are just as pressing, especially in a society in which more and more of us can look forward to a life of old age and infirmity.
	What should really constitute the blot on our social conscience is that adult social care is not widely seen as being in crisis. More and more people are eking out an existence in a condition of social isolation, deprivation and neglect, which is set to get worse unless something is done about it. There is not much evidence that anyone proposes to do anything very much about it. That is what I may call a chronic crisis: one that persists from year to year below the radar of social concern; below the level that attracts the "shock, horror" headlines—which is what it seems to take to promote action.
	I feel increasingly like Sir Mike Jackson when I observe the disconnect that seems to exist between official diagnoses and professions of intent, which seem to inhabit some kind of bubble removed from reality, and what is happening on the ground. Let us take the White Paper, Our Health, Our Care, Our Say, published in January 2006. It placed great emphasis on prevention and providing greater choice and better access to community health and social care services for users. Launching the White Paper, Patricia Hewitt said:
	"We focused a huge amount of effort and resources into reforming the NHS and social care through extra capacity in hospitals, more facilities and supporting more older people than ever before to live independently.
	Today's White Paper moves us on to the next stage of our improvement and signals a major change in how health and social care will work together in the future".
	The Local Government Association reports that demand for social care is rising by 6 per cent every year. In the next three years alone, there will be more than 400,000 more older people, many of whom will require social care, but there will be no extra resources to deliver it.
	In reality, the number of older people supported by social services has been shrinking from 528,500 in 1992 to 354,500 in 2005. Last month the LGA stated that, without additional funding, by 2009-10 up to 370,000 older people currently receiving free, low-level care could have it withdrawn completely. I am not quite sure how those two statistics, taken from different sources, stack up against each other, but what is clear is that there are likely to be major cuts in provision.
	Since April 2003, every local council in England uses the national framework known as Fair Access to Care Services, according to which people's needs are to be assessed as critical, substantial, moderate or low. It was aimed to create greater consistency across the country in deciding whether people have services. However, since the ruling in the Gloucestershire judgment, which allowed local authorities to take resources into account when allocating services, FACS has failed in reducing the postcode lottery of service provision.
	In March 2006, the finance committee of the Association of Directors of Social Services outlined the severe financial problems that many local authorities were facing and warned that only those people who fall into critical or substantial categories of need, as set out in the Fair Access to Care system, will receive services. Seventy per cent of local authorities have tightened their eligibility criteria. In the coming year, eight in 10 councils are set further to tighten their eligibility criteria.
	That has a number of untoward consequences. One is that anyone not in the critical or substantial category has little chance of getting vital equipment that they need to function effectively in the community. If you have a mobility difficulty, you will be able to get a wheelchair, but those with a visual impairment will be lucky if they can get a white stick. It needs to be recognised that people with sight difficulties may be dependent on communication aids that are just as expensive as a wheelchair, such as a closed-circuit television or a computer.
	In that connection, it is worth remarking that there are many inefficiencies in the equipment service. Major economies of scale could be achieved with a system of national purchasing or commissioning for local delivery, such as the RNID has recently achieved from the hearing aid service. The review of the equipment service recently set up by the Prime Minister is thus very welcome and it is to be hoped that it will prove to be a vehicle for getting rid of many of those inefficiencies.
	Secondly, the system is largely geared to managing crisis rather than supporting people to live independently, with dignity and a good quality of life in the community. Thirdly, it is putting people at risk. The Commission for Social Care Inspection's recent report, Time to Care, found instances where people's safety and well-being have been compromised by inadequate support. According to the Audit Commission, in 1999, there were 190,000 A&E attendances as a result of falls by people with a visual impairment, which cost hospitals £270 million. Nearly half of those were as a direct result of visual impairment, at a cost of £130 million.
	Fourthly, leaving people to fend for themselves until they reach crisis point is no doubt meant as a means of rationing resources but, in fact, it not only fails to meet their needs but is extremely wasteful. Much unnecessary bureaucracy is involved in multiple assessments. It would be a good deal more cost-effective if people were given the right kind of help—the kind of help that they want and the kind of help that they really need.
	These points are well illustrated by a case cited by Sense, which works on behalf of deafblind people. It concerns an elderly deafblind lady, who was identified by her social services department as deaf and provided with an induction loop. However, the instructions were in small print that she could not read. She was also identified as blind, and a white cane was delivered, but she could not receive training to enable her to get around using it because the instructor could not communicate with her. She was then identified as socially isolated and referred to a day centre, where she could not communicate because of the noisy environment and the lack of communications skills of staff and other users of the centre. Finally, she was provided with home-care workers five days a week but, again, they could not communicate with her. The notable thing about the services offered to this lady is that they cost a considerable amount of money but gave exceptionally poor value. A service that would meet her needs more effectively, such as regular access to a trained one-to-one worker, would almost certainly be less expensive, and it would without doubt be more cost-effective.
	What needs to happen? The noble Lord, Lord Bruce-Lockhart, has rightly reminded us that the way in which we treat the most vulnerable members of our society should be seen as a yardstick by which the moral health of that society should be judged. National standards and frameworks exist for many different groups, but not for people with specific disabilities. I declare an interest as chairman of the RNIB, which worked with Guide Dogs and the Association of Directors of Social Services to develop a new national service framework for blind and partially sighted people, called Progress in Sight. It would be a great help if standards such as these could be given official, even statutory, recognition by government, and I should be very interested to hear from the Minister whether she would be prepared to consider this.
	Secondly, we need to give the Disabled Persons (Independent Living) Bill of the noble Lord, Lord Ashley, a fair wind as the best prospect for moving forward. This would place a duty on local authorities and NHS bodies to co-operate with each other and with key partners, such as Jobcentre Plus, to promote independent living and improve outcomes for disabled people. The DRC is calling on the Government to renew investment in independent living for disabled people of all ages to improve their life chances. One person in government recognises the need for such investment. At the Labour Party conference in September, the Chancellor said that the state of services to disabled and older people was one of this country's greatest social-policy failings. It is greatly to be regretted then that nothing was said in the Chancellor's Pre-Budget Statement yesterday about making available the resources needed to remedy this situation.

Baroness Sharp of Guildford: My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for introducing this timely and relevant debate. I declare an interest as the chair of Age Concern Surrey. I want to talk particularly about the results of a survey that we undertook on the well-being of older men in Surrey. Surrey is similar to Kent and I recognise the general situation explained by the noble Lord, Lord Bruce-Lockhart. Our population is about 1 million, which, by 2020, is due to rise to 1.16 million. At present, 16 per cent of that population are aged over 65, which will increase within the next two decadesto 21 per cent. As the noble Lord suggested, a disproportionate part of that change will be in the over-85 age group.
	We also face the same problems concerning social services. Surrey has a relatively healthy and wealthy population. Therefore, funding allocations to the National Health Service and to local government are low. Equally, we have a very articulate and demanding population. It is very difficult to fund what is supposed to be a demand-led health service with the funding allocations that are made to that service. Therefore, we face, as do many other PCTs in the south-east, considerable overspend beyond what is allocated. Currently, the economies being made are cutting back on acute care. Noble Lords have already talked about the overlap between social services and the NHS. The earlier bed-blocking problem has been solved, in some senses, by social services picking up the tab. However, it is increasingly difficult for them to do that. In particular, local social service low-level care has been more or less totally withdrawn. The only care provided is for those who require extremely high levels of care.
	There are huge problems. Age Concern Surrey has been running services to provide low-level and more personal care. It is difficult enough to find people to provide those services, but CSCI's increased demands for training and for carers to have NVQ Level 2 have made it impossible for us to meet the overhead costs associated with running the services, so we have had to pull out.
	The survey that I mentioned looked at lone older men. Although the number of widowers is likely to fall, the number of those who are divorced is increasing rapidly. As a result, about one in three of the population aged over 65 is single. Increasingly, that will include older men. There has been very little research intothe involvement of older men in the community. Disproportionately, women have traditionally been the partners who form and maintain social networks, and acquire knowledge of support systems, such as the NHS and social services. The services are geared to this larger, more visible and more vocal population of older women. Men are less willing to ask for or accept help and less aware of what is available. The lack of social support networks means that many of them, without people realising, are extremely depressed by being left on their own.
	What are the key conclusions? First, as has been mentioned already, retaining independence is extremely important. We need to be able to offer low-level care— domestic cleaning, shopping, washing and so forth—in such a way that individuals retain control over their own lives. Getting in early is also extremely important.
	Secondly, social networks are vital. We need to involve older men in their 60s and 70s in social networks before they become unable to travel easily. They can themselves build networks for older people, and being involved in volunteering in this way can help a great deal. Transport is a key consideration, particularly for those who have to give up driving. It is very important that there is more sensitivity in regard to transport. Someone who was surveyed said:
	"Dial a Ride will only take you where they want to go, not where I want to go".
	Thirdly, there needs to be sensitivity in offering help. Elderly gentlemen have to be coaxed to seek help and are easily discouraged from seeking further help. Information and advice services are easily available and in a user-friendly form, but there was a very strong plea for "no automatic telephone answering". People did not want to be passed on from one bureau to another or to have to ring up one agency after another. One-stop shop help is extremely important. It is also important to be sensitive with the older generation when providing, for example, bathing or personal hygiene services. There are obvious sensitivities about all helpers being female and it is important to try to provide male helpers in such circumstances.
	It was an interesting survey and I have touched on only some of the main conclusions to emerge from it. It is quite clear that the demand for help and services for this group will increase, not diminish, and the development of social networks is vital. This House provides a very good social network and, in many senses, those of us who are in the age group who will be looking to these services gain so much from it.

Lord Dearing: My Lords, I am grateful to the noble Lord, Lord Bruce-Lockhart, for initiating the debate because it enables me to share with the Minister a problem that has been growling in my belly for the past two years. I declare an interest as a trustee of a home for the care of old people. I do not expect the Minister to reply to the specifics of what I have to say but I think it illustrates a more general problem.
	The home was created 100 years ago for the care of old, poor people. The people who come to us are in the aged mainly between 85 and 90. They are not the kind of people who can be looked after for five hours a day in their home. The home has provided a valuable service to the community for a century.
	Representatives of the Care Commission visited the home two years ago—and here is the problem—looked round and said, "Thou shalt do this and that", including, for example, increasing our staffing. This visit added £150,000 a year to our costs but the local authority has not been able to increase its payments to us. As a result, we lose £5,000 a year for every one of the 30 beds we provide for the needy, poorer people in our community. One public body demands—and if one does not respond one can be closed—and yet the other public body is unable to meet the bill.
	Although the Government do not require single-room accommodation from bodies such as ours which have been providing care for such a long time, the Care Commission makes it absolutely clear that this is what it expects. However good our care may be, we can never get a better rating than "adequate" because we are not providing single-room accommodation. We would love to refurbish and reconstruct but, at the rates the local authority can afford to pay, that will not be possible unless we move from caring particularly for the poor towards looking after those who can afford to pay at rates of £200 or £300 a week more than we need if we are to care for the poor.
	The local authority has its own financial problems and it is perfectly entitled, under Section 26 of the 1948 Act, to shop around and find rooms where it can, here and there, at marginal cost, in private sector nursing homes. But you cannot run a home on marginal cost when catering for the poor. You can do that only for a few beds.
	My point is that we are all driven to short-termism. I do not see how the needs of poor 85 to 90 year-olds will be met in the long term if places such as ours cannot continue specifically concentrating on care for the poor, rather than moving over more towards a different market. I ask the Minister to look at this as an illustration of an issue that will not go away and will get worse. How can the Government reconcile having a public commission with the power to require while not providing the means of meeting those requirements? It just does not add up.

Lord Hanningfield: My Lords, I begin by congratulating my noble friend Lord Bruce-Lockhart on securing this enormously important debate. He spoke with his customary eloquence and authority, and we have had other good contributions. This serious issue is now impacting on every local authority in the country, and, in turn, not just on the elderly or disabled but on every user of local services. Before I begin my comments I must declare an interest as leader of Essex County Council. It is from this experience and in this capacity that I have first-hand knowledge of the seriousness of these problems. I will turn to the position within my own authority a little later.
	It is not an exaggeration to say that the problem of adult social care is now the single largest challenge facing local government today. Ever-growing numbers of elderly people with cases of ever greater complexity, combined with a government grant that has failed to match that spent on key services, means that services for the elderly are teetering on the brink. The present situation is unsustainable. Knock-on effects are being felt.
	It is clear that despite significant cost savings made by local government—even the Government recognise that efficiency savings in local government have been better than in their own services—all services are suffering, and resources are being diverted away from other services to fund the spending on elderly care. That problem is not confined to any one geographical area; nor is it dependent on the political party in control. It is faced by every local authority in the country.
	One needs only to look at the letter published today in the Guardian to see the extent of the concern: 40 leaders of some of the largest local authorities in the country say that the present situation is not working. I hope and trust that the Government will take a moment to listen and, with any luck, will conclude that something is indeed going wrong. What we do not need from the Government are comments such as those we have seen in recent weeks dismissing the scale, size and seriousness of the problem. We were disappointed by that approach. It helps no one.
	The reality is stark. Over two-thirds of local authorities provide services only to those at substantial or critical risk. Many authorities are having to consider whether eligibility thresholds will have to rise. To date, the vast majority of authorities have held off from raising those thresholds, but the position cannot last much longer. If this process of rationalising care were happening in the NHS there would be a public outcry, but, as the noble Baroness, Lady Barker, said, these tend to be "Cinderella services" and do not get the publicity they need.
	This problem has arguably been long in gestation but it is now very much facing us in the open. Each strand has come together to put these services on the brink. Chief among them, as several noble Lords have said, is the growing number of over-85s requiring some kind of support. We welcome the advances in healthcare that have made ever-growing numbers of people live longer, but there is an ever-growing dependency on social care services. Side by side with the growing numbers is the complexity of diagnosed cases. Complexity of cases inevitably leads to much more expensive care packages. This is further compounded by the NHS moving towards short-term interventions. We have heard a lot about preventive work today. I agree that when the preventive work is cut back, the long term suffers.
	The root cause of these problems stems from the financing of these services, and we must do something about that. In aggregate, councils with social services responsibilities set 2005-06 budgets 13 per cent above the notional requirement calculated by the Government. I cannot help but think that the Chancellor missed an opportunity yesterday in the Pre-Budget Report when he took £3 billion in taxation. As much as we all support extra spending on schools—I have spent a lot of my time in local government supporting education—we could have had some recognition of the support our elderly people need. It is about time that some money was diverted to that area.
	As I said, I am leader of Essex County Council and I face these problems daily. We provide 25,000 care packages in Essex; adult social care currently accounts for 43 per cent of the county council's net revenue budget. We are a big local authority, and our net budget is something like £1.2 billion. A tremendous amount of money is going on adult social care. Over the past decade, spending has risen by an average of 9.3 per cent a year. I repeat: this is unsustainable. We had a 2.7 per cent grant increase last year, 2.7 per cent this year and we will get the same amount next year. Local authorities are unable to maintain services with such an increase in grant settlement. Other services are being cut back dramatically to finance adult social care. In my county, the 85-plus population is growing at twice the rate that it does in other areas. We are a coastal county and, in common with other such places, a lot of people have moved there.
	I know that the Minister cares about these things. She cannot deliver the money but the Chancellor can. I ask her to persuade her colleagues so that local government can get extra respite to finance dealing with some of these problems.

Lord Taylor of Holbeach: My Lords, I am grateful for the opportunity to support my noble friend Lord Bruce-Lockhart. As the debate has shown, this is a discussion about the inadequacy of resources to meet the needs of contemporary adult social care. I shall talk about older people's care but I recognise that adult social care has a wider scope, as the noble Viscount, Lord Tenby, reminded us.
	I begin by declaring two interests. First, for the past 18 years until recently I was chairman of the charity that runs Holbeach Hospital. I remain a trustee of a project which is an exemplar of community action, which since its closure by the health authority has doubled capacity with nine doctor beds, outpatient facilities purchased by the PCT and 37 high and higher dependency care home beds. There is more to say on this but time is short. Noble Lords will appreciate that I have seen how funding problems in the health service and social services can impact on providers. How I identify with the comments of the noble Lord, Lord Dearing. Secondly, I am married to a Lincolnshire county councillor of long standing, so from time to time I am subject to intense briefing.
	We have heard of changing demographics. In Lincolnshire the population aged over 65 is growing at between 4.5 to 5 per cent per annum. This increase alone is costing £6 million per year just to maintain the status quo. To improve services to desired levels would take £11 million per annum. Some of this growth is coming from people retiring to live in the county. They are welcome; they strengthen our communities, but in the main they are not rich, and most of them quite rightly will need support and care in their older age.
	Care services are also vulnerable to wage cost inflation. They are labour-intensive, often one-to-one, and more often than not are provided by lower waged staff who have rightly benefited from higher than inflation increases in the national minimum wage. We create costs too by the bureaucracy that is part of the care culture of our time. From CRB clearances to inspections, those costs take resources away from front-line provision. Even a short inspection can cost a local authority upwards of £300,000. That is enough to provide 25,000 home care hours, or full-time residential care for 20 people a year.
	Financial pressures usually lead to short-termcost savings, which are usually very inefficient, including skilled-staff redundancy, reorganisation and reconstructions. All of it is taken from providing care. Underfunding can lead to a withdrawal of service in different ways, and we have heard examples of those. We know of the post that is not filled in too much of a hurry, the cover that is not found for short or long-term absentees, and the overt or covert failure to encourage take-up. Worst of all, it encourages voices that say, "Don't shout about it too much; they will all want it". No, my Lords, we must shout about it. It is the mark of a civilised society that it cares for its older citizens in a proper way.

Baroness Scott of Needham Market: My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for bringing the debate forward today and for giving us the opportunity to discuss these issues in what has been a remarkable set of speeches. They have been remarkable for the breadth of experience that lies behind them, and for the consensus on the scale and size of the problem and its root causes. I shall use my time to concentrate on the situation that is faced by local authorities. As other noble Lords have spoken so eloquently about the plight of individuals in need, there is a risk that my remarks might sound rather technical, but I assure noble Lords that in fact all my sympathies lie with those who are not receiving the care that they should.
	Local authorities have been facing a stringent financial situation for some years now. I know that the Minister will argue that the 40 per cent increase in funding to local government from central government over the past 10 years has been generous. I know that the Local Government Association will argue that because most of that money has been ring-fenced for school spending, the actual increase available to local councils has been closer to 14 per cent. It says something that we cannot reach consensus on the starting point for the debate.
	There is no doubt that in the past decade councils have faced a growing demand for their services right across the piece. For example, the number of people aged 85 and over has increased by 6 per cent a year. Their needs become more complex; 25 per cent of them will develop dementia and will require a high level of care. We have heard a lot about that, particularly from the noble Lord, Lord Dearing, with his experience. As NHS budgets are squeezed, almost half of local councils are reporting a reduction in PCT support for joint projects. An LGA survey carried out in June shows that 70 per cent of local councils have been adversely affected by actions such as bed reductions and community hospital closures.
	It is not a one-way street. Local authority cuts, especially to carers, can often result in pressures on the NHS. At a time when we have never needed co-operation between the NHS and local authorities more, the danger is that they will retrench into positions that simply protect their own budgets, rather than thinking about value for money and service to the people who need it. Central government has placed new burdens on local councils of new legislation and inspection and target regimes.
	Local authorities have absorbed those costs and pressures, just as they have had to absorb costs that have increased ahead of inflation in other areas such as waste disposal, road maintenance and energy. We know that unit costs in privately run children's homes have increased by 45 per cent, costs of social care contracts have increased as the impacts of minimum wage compliance have been felt and the demands of CSCI have increased costs, too. As the noble Baroness, Lady Greengross, and the noble Lord, Lord Dearing, put it so elegantly, even so, given the pressures on local authorities to pay more, they are still not paying enough to manage care homes properly. The difference is being picked up by the voluntary sector and by the families.
	Councils are currently spending on social services some £l.8 billion above the amount allocated to them by central government. That money can be met in one of only two ways: either by increasing the council tax or by making cuts in other services. The difficulty for local authority leaders—and I know from experience what this is like—is that social services, after education, has by far the largest pot of money. One can make huge cuts in other areas of service delivery, but they make only a small difference compared with the social services budget. The noble Lord, Lord Hanningfield, mentioned that 43 per cent of the Essex budget is spent on social services, so there is very little scope for local authorities. They cannot keep increasing council tax, nor can they keep cutting other services to deal with demands in social services.
	Changes to the way in which government grant is assessed can have a significant effect on individual councils, even where the overall effect is neutral.For example, Luton council tells me that it lost£5.9 million through the operation of the Government's damping mechanism. Reductions in funding through the Supporting People programme have been reported by Luton as £170,000 and by Somerset as some £2 million. In Bristol the figure is some £3 million.
	According to the Commission for Social Care Inspection, increased demand has already led to,
	"a gradual reduction in the numbers of older people receiving state funded home care",
	and,
	"the tight targeting of statutory support towards those with critical levels of need".
	Wanless made similar comments and said,
	"there is evidence of significant unmet need".
	Speaker after speaker in today's debate has referred to this erosion of low-level care, which makes all the difference to the quality of people's lives and ultimately to their ability to stay in their own homes for longer. The contribution of the noble Lord, Lord Low, was especially interesting, as he emphasised how changes in eligibility criteria, year on year, can affect particular groups in a special way—he mentioned the visually impaired.
	If one believes everything that one reads in local newspapers, one would think that this is all because local councils are simply inefficient. There is no evidence to suggest that. Local government has a strong record on financial management and service improvement, as was judged by the plethora of inspecting bodies that the Government have thrown at them in recent years. The Audit Commission performance assessment shows that 68 per cent of councils achieve 3 or 4 stars—out-performing the NHS by a long way. The Commission for Social Care Inspection only last week announced that local authorities have improved for the fourth year running. There are now no zero-rated authorities and 78 per cent are in the 2 and 3-star categories. The noble Baroness, Lady Pitkeathley, paid tribute to the role of local authorities over the years in the delivery of social care.
	Local government has achieved its Gershon efficiency target of 2.5 per cent savings per annum—a year ahead of target and faster than central government departments. I have no doubt that local government has been and will continue to be capable of rising to challenges, but it cannot keep doing that unless there is a complete change in the strategic framework to one that genuinely reflects the needs of people and, more importantly, how it should be funded.
	On current trends, by 2009-10 local authorities will no longer be able to provide support and care, other than to those in critical need. We currently provide home care to 370,000 people. That figure is low by international comparisons and we should not contemplate allowing it to drop further. Demand for help from those with learning disabilities is increasing. Somerset has identified the need for 35 new places by 2010. That may not sound like very many, but the cost to that authority will be more than £1 million a year. The total population in England is expected to rise by11 per cent over the next 30 years, with the largest growth in the over-85 age group. Stockport council has told me that it provides support to one in two people aged 85 and over in its area.
	We need to maintain a committed workforce to achieve our aims. The objective of managing costs cannot be entirely at the expense of a high-quality workforce. The noble Baroness, Lady Verma, made that point very well. Recruitment and retention is already a major issue in social care, and vacancy rates are high.
	The 2007 Comprehensive Spending Review provides a real opportunity to consider how we should meet the needs of the elderly and those with disabilities. It should not be a matter of how little care we can possibly get away with; we should be using as a benchmark a level of care to which we ourselves would aspire when the time comes.
	The Government now have to make a serious choice about matching their vision for social care with the means available to fund it. The burden cannot be surreptitiously pushed on to council tax payers, as it has been in recent years. On these Benches, we hope that when the Lyons review eventually comes out, it will have something to say on this matter.
	The noble Baroness, Lady Greengross, had it absolutely right when she said that central and local relationships are at the heart of this issue. Both local and central government have a vision of improved public services which offer a better quality of life for citizens. Both can play their part but there must be a mature debate and agreement on how we move forward. The annual game of claim and counterclaim between both sides, while people see their local services cut, helps no one.

Baroness Hanham: My Lords, I, too, congratulate my noble friend Lord Bruce-Lockhart on obtaining this debate and on proposing it so cogently. I declare an interest both as a chairman of an acute hospital and as a member of a London local authority.
	The noble Lord's excellent speech has been followed by those from other very well informed speakers, from whom there has been an unusual degree of unanimity. They have all demonstrated the problems of lack of resources or lack of continuity between various authorities.
	The debate has demonstrated the difference between rhetoric and practical application. I want to touch a little on the National Health Service. I know that it was the subject of the previous debate but it is relevant to what we are talking about here. There have been policies for at least six years to reduce the amount of time that people spend in hospital and to provide both medical and social care in the community so that people have a choice in the way that care is provided, and by whom, and so that they have freedom to fund their requirements in their own way. But that has been in the complete absence of a coherent policy for funding the major "turn" in the structures of care. There are aspirations, of course, but these are continually thwarted by crises in budgets and funding. The policy needs both local authorities and the National Health Service, in the form of the primary care trusts, to work together to provide the funding and expertise. However, because of increasing cost-pressures and deficits within the health service, in particular, there is a black hole in the amount of money available to support it.
	My noble friend Lord Bruce-Lockhart touched on the subject of that black hole, and other noble Lords mentioned it too. It is amounting to about £1.8 billion this year. Seven out of 10 local authorities have been hit by reductions in funding not only from central funds but also in the form of funding that they were expecting from primary care trusts. That is hampering the implementation of the policy of greatly extending local authorities' responsibility to work closely with the National Health Service to bring down the number of people in expensive hospital beds.
	It is no longer the position that even patients who have had intensive medical treatment cannot return to their homes provided that there is a well considered and planned discharge programme, with proper and adequate professional care involving the services of both the primary care trust and the local authority.
	The implementation of this policy is starting to bring about a reduction in the number of beds in hospitals, albeit that the practicality of social care in the community is not one that is widely or well modelled across the country. This is a major change in the structuring of care, needing all the right professionals in place and sufficient of them—this has been touched on by other speakers—to manage a full range of care, from intensive long-term care to a more short-term involvement.
	As yet there is not a system that is universally available, nor the requirements for, or costs of, which are fully understood. What is clear is the need for a close working relationship between local authorities and the health service so that there is a seamless responsibility between them. The absence of reliable funding to enable this to be planned and implemented widely is reducing the choice that should be available to patients on discharge.
	Many noble Lords have touched today on the care of the elderly, and the respectful approach to their care has been high on everyone's agenda since, particularly, the publication of the National Service Framework for Older People in 2001. I am chairman of the national service framework in my hospital.
	More than 65 per cent of patients in hospital at any one time are over the age of 70. At any one time, 1.5 million of the most vulnerable people in society rely on social workers and support staff for help. An estimated 1.23 million people who received help and support from social services in 2004-05 were living at home and were over 65 years of age. That is a significant proportion of the population. If they need and qualify for help, there is a vast amount of work for both the local authorities and the health service to undertake. In doing so, it is essential that those who require help with day-to-day living are left with choice and flexibility in how that care is provided, and a reassurance that they can rely on it. But that, as my noble friend has said, will depend on the budgets available to sustain it.
	In an era when more and more funding seems to bring blacker and blacker holes, we have to face up to the fact that social care in the community and looking after people in their own homes, which is now their overwhelming preference, is not a cheaper option than residential or institutional care. While it is much more desirable, it is in many cases more expensive because it is individualised and personal. This is a road on which we are embarked, and which rightly will continue. The NHS is reducing the amount of nursing accommodation in favour of more home care, and that home care is being transferred to the local authorities. The number of residential homes provided by local authorities is being reduced in favour of home care, supported housing and extra-care sheltered accommodation. People who can, are encouraged to make their own arrangements and are helped by the still limited scheme of direct payments, which enables them to buy their own care.
	There are failings, which have been amply demonstrated by the noble Lord, Lord Dearing, and the noble Viscount, Lord Tenby, in describing what is plain to us now. There is a divergence and dichotomy in the bureaucracy over how care homes should be and the practicalities. More are shutting now because of bureaucracy than because of the practicalities of ensuring that people can stay living in the homes where they wish to do so.
	The noble Baroness, Lady Verma, also gave a very clear indication of what happens for packages at home. We need to give people in their homes the care that they need, which is not cheap. We also need to be sure that there is respite care. Many noble Lords touched on the benefit of carers and the amount of time that they provide for free in looking after people in their homes. They need to have respite care from time to time.
	There is so much change but, when in dire straits with funding, both the National Heath Service and local authorities resort to waiting lists or tightening of eligibility: rationing care, as we have heard. Many people who need their services do not necessarily get them, nor do they get what they want when they want it.
	Finally, I was talking to a social worker just the other day who was about to discharge an elderly patient from hospital to supported care at home. I asked her what that meant, and she said "Oh, she will be visited four times a day". I asked whether that included the night-time. "Oh no," she said. Somebody was being discharged home to be looked after and fed occasionally during the day, with nobody there at night. I did not ask if there was a carer there at night, but I am not sure it would have mattered. That was the package she was going to get.
	As all noble Lords have said, choice and independence lie at the heart of what we all profess to believe. We are not delivering them. My noble friend Lord Bruce-Lockhart has today introduced an extremely important subject. All speakers have demonstrated the black holes which need to be filled if the Government's policy of social care in the community, looking after those who need it, is going to mean something.

Baroness Andrews: My Lords, I join all noble Lords who have congratulated the noble Lord, Lord Bruce-Lockhart, on such a timely and excellent debate. Not only does he bring his own authority and experience, but he has enabled noble Lords around the House to talk with great authority from experience of local authorities, bringing a wealth of insight and illumination to some of the situations on the ground.
	In many respects, I am happy to join the consensus he raised, bringing others in your Lordships' House with him, about the scale and seriousness of the challenge and the reasons for and dimensions of the pressures of demographic change. I take issue with him and some other noble Lords, however, on his allegations of the absence of funding, failure and the idea that the Government somehow lack a sense of urgency. I shall try to address those.
	It is a pleasure to be at the Dispatch Box. Speaking for the Department for Communities and Local Government gives me an opportunity to represent the Government speaking with a single voice on social care, work and pensions, which many people want to hear. I hope that that is a good start to a debate which affects each of us and covers the whole range of what government is for. Those who depend on social care need to know that. In the light of the pressures identified by noble Lords, they also need to know, as the noble Baroness, Lady Scott, said, that there is a mature debate: we are looking at the same pressures in the same ways, using the same language. The most important thing is the fact that we have been working closely—nobody knows this better than the noble Lord—with the Local Government Association and the Association of Directors of Social Services in a working group since the beginning of 2006, which has informed the debate. We welcome that collaboration and are committed to working throughout theCSR 2007 process—the opportunity that the noble Baroness, Lady Scott, indicated—to ensure that they are engaged in all stages of the process. That way, we can identify in specific ways the pressures which have been identified this afternoon, as well as considering how they can best be mitigated. From what noble Lords say, we are approaching diagnosis of and strategy for problems in exactly the same way.
	The LGA is engaged in CSR work schemes across government. It is too early to predict the outcome of the process; we know that the next spending review will be tight, so it is important to be clear and frank about that. That partnership means a lot to us. For example, local authorities have benefited from the grant settlements we have been able to provide for councils this year and the next, with an extra£800 million above existing spending plans.
	The pressures have been extraordinarily well described in a variety of ways in the contributions made by the noble Lord, Lord Low, the noble Lord, Lord Dearing, who spoke about care homes, and by the noble Baroness, Lady Sharp, who drew attention to a group that is often overlooked because it is relatively invisible and new to our conscience. The noble Viscount, Lord Tenby, drew attention to the increasing number of young adults with complex disabilities and the fact that they are living longer, which puts great pressure on the system. As the noble Baroness, Lady Verma, said, we have a responsibility to provide services that are not merely appropriate but of the quality that we would want for ourselves and our relations.
	There is no difference between us. We know the pressures that local authorities are under. The Secretary of State for Health recently told the ADSS that she recognised that this is a tough time for directors of social services and that many of them feel that the Government are asking them to do more when they are running to stand still. Yet every example that noble Lords offered this House is an example of real experience. I could offer some excellent examples, as we all could. Nevertheless, we are talking about the way the vulnerable in our society need the social services that we offer. We are aware of the scale of the challenge. I shall not go over the statistics because they have been well described and they are bound to increase, given an ageing population.
	The consensus extends to the Wanless report. I shall say a word about timescales. We are dealing with the challenge of three timescales: the immediate, the sort of things we have been talking about this afternoon; the interim, in relation to CSR 2007; and the strategic framework referred to by the noble Baronesses, Lady Scott and Lady Hanham. That needs to be a robust strategic framework with an understanding of future needs, and that is what we asked Derek Wanless to produce. We have not yet addressed it because we are working with him on the interim and the long-term, but we will. The good news is that the challenge of providing for an ageing population is relatively predictable as we move towards more stable financial frameworks with multi-year settlements and local and central government working together.
	The noble Lord, Lord Low, suggested that the Chancellor has not recognised that there is a problem. Yesterday, in the Pre-Budget Report, the Chancellor referred to the sharp rise in the number of old people that is expected in coming years. Sir Derek Wanless and the Joseph Rowntree Foundation are feeding in to the assessment that is going into CSR 2007. We want to offer progressive universalism, but we also want independence, dignity, well-being, personal control and affordability in the future system. We have also flagged up some new ways of working. They are set out in Our health, our care, our say, in the National Framework for Older People and in Improving the Life Chances of Disabled People and the messages are the same.
	I have to respond to the challenge that the Government have not acted by giving some statistics and dealing with some statements that were made. The investment that we have brought forward has seen a total government grant for revenue spending for local authorities of £65 billion, which is an increase of 39 per cent above the rate of inflation. Over the past 10 years, we have had a grant increase above the rate of inflation. Last week, I was able to confirm the increased investment in local services that we announced as part of the first stable and truly predictable settlement for local government. That settlement was closely informed by what local authorities said they wanted. However, I have to take issue, in the nicest possible way, I hope, with the statement that somehow the increase outside spending on education has been only 14 per cent. There are several problems with that figure. It is simply not possible to compare like with like because government funding for education was not hypothecated in 1997 but now is. It is extremely difficult to disentangle funding streams. Secondly, the 14 per cent figure excludes specific grants, which are grants given to local authorities for specific purposes. In the case of social care, that provides a distorted picture because £14.6 billion has been given in specific grants for social services since 1999-2000. So it is not right to say that the increase in local government funding, excluding education and specific grants, has been 14 per cent in real terms since 1997.
	We are now consulting on formula funding. On top of the fact that, as I said in the Statement last week, we have funded for these new burdens separately, local authorities will benefit from government grants of £1.6 billion for specific initiatives in added social services in 2007-08. That will aid budgets, as most are not ring-fenced and therefore decisions can be made. They go alongside, as the previous debate in the House rehearsed, massive spending in the National Health Service. It is significant additional provision, which has attempted, by best evidence and working in partnership, to meet and identify the pressures within the system. It has led, for example, to the fact that, since 1999, local authorities have doubled the number of intermediate care beds, which helps people avoid hospitalisation. I do not put these arguments to diminish anything that has been said about situations in local authorities or those in the personal examples, but it is only fair that we recognise the evidence and the effort that has gone into funding, which is a major challenge in this country.
	The other main argument made this afternoon—that there is real pressure on local authorities justto fund substantial and critical care—is well documented. We know that local authorities have to make difficult choices. CSCI has recently reported that the majority of councils are setting the threshold for care-managed services as substantial. That does not mean that the system is about to collapse. It does not mean that it is in chaos. Half of councils are still supporting the threshold of moderate means.
	People are receiving the essential low-level services which make the difference between keeping them in the community in safety and not in hospital—for example, the kind of situation when a person has an unnecessary fall. I absolutely agree with everynoble Lord who has commended local authorities on how they have responded and on the massive improvements in the system. We have to see the changes in the context that CSCI has also said that social care services for adults have improved for the fourth successive year. What a credit that is to local authorities. Three-quarters of councils have two or more stars and have exceeded their efficiency targets. However, the argument has been that however much extra funding there is, however many efficiencies are made and however efficient local authorities are being, that is still not enough and there is a great deal more to be done.
	It has been suggested that somehow health and social services are not only not joined up but are in opposition. Nothing could be further from the truth. The delayed discharges Bill was able to bring people into the community, releasing health service beds for people who were in more critical need of them. We have seen a 5 per cent shift of resources from secondary to primary care, but the Secretary of State for Health has also acknowledged that in some places social services are having to pick up the pieces as the NHS withdraws and vice versa. It is not good enough. We are not going to defend that. Social care and healthcare are both sides of the same coin. We do not want this to be a game of pass the parcel. That is why I want to talk about how we are addressing and going forward with local authority partnerships.
	A great deal has been said about care homes. The noble Baroness, Lady Greengross, and the noble Lords, Lord Low and Lord Dearing, spoke about this issue. These are very specific and special situations. I cannot answer the specific instances, but we should look at the range and choice in the quality of services that we want to offer with care homes.
	I turn to the argument about prevention and independence. At the heart of everything we have been trying to do—noble Lords have recognised this—is this move towards prevention and keeping people out of care-managed services and providing appropriate support. We know that the NSF for Older People set a target of improving the quality of life of older people by ensuring that 30 per cent of people receiving social services did so from home. That target has been met two years ahead of schedule.
	Many of those services and prevention have been mediated through our 6 million carers. I am surprised that it is only a hundred years for which my noble friend has been working for the Carers' Association. She has done a magnificent job. She and the noble Baroness, Lady Verma, will want to know that the department is already working hard with carers' organisations to update the 1999 document so as, for the first time, to put a real priority on carers—for example, to develop guidance on best practice in the provision of emergency respite care. It is crucial for them to be able to predict when they can get away. We are very serious about ensuring that people have the respite that they need.
	On the commissioning argument raised by the noble Baroness, Lady Barker, and my noble friend Lady Pitkeathley, yes: in the third sector review, we are looking hard at how we can introduce more stability to the voluntary and community sector, precisely so that, through our three-year programme, it can provide a much more predictable and stronger role.
	Independence and choice? Yes. There are developments such as extra-care housing. We now have 3,000 extra-care units providing 24-hour support. The point about independence and how we will deliver services better is that we need to know more about how to deliver it. That is the purpose of the partnerships for older people project—how to pilot it so that we get the best not just for the elderly but for people such as those about whom the noble Viscount, Lord Tenby, and the noble Lord, Lord Low, were talking: people who need consistency of care. They need the person beside them in the community daily, when they want them, whether it is night or day, rather than a procession of different carers and options. That is the purpose of the project, and that is the model for independence that we are trying to work through.
	That leads me to the great pressures, to which we must respond, for joint commissioning. When you have an individual budget and model for a person, you must have joint commissioning to bring the services together. We have seen an explosion of partnership arrangements: £3.25 billion of core resources have been used in recent years. The shape of the future is independent budgets for people.
	I turn to the wider strategy. There is a changing landscape. Perhaps the greatest change will come from the new settlement between central and local government and the community that will be introduced via the White Paper on local government. I could not agree more with what the noble Baroness, Lady Scott, said about the implications of moving from centralised targets to local objectives. The White Paper will help everything that we have discussed in specific ways. It provides the framework for more visible leadership on health and well-being in cross-cutting issues. There will be a lead member on local authorities who must play a leading role in health and well-being partnerships. Local authorities and the NHS must work towards a coherent set of priorities and targets, rather than pulling in different directions. It will strengthen the commitment of other partners by placing a duty on the health service to co-operate with local authorities through LAAs, which will be statutory. Those strategic frameworks will make the difference. Of course, that will come alongside the Lyons review and the long-term funding horizons.
	A great deal is happening in this area. I am conscious that I have not referred to all noble Lords who spoke, let alone answered their many questions—for example, the cases raised by the noble Lord, Lord Hanningfield, in Essex, the noble Lord, Lord Taylor, in Lincolnshire, and the noble Baroness, Lady Gardner of Parkes, who introduced the perspective of the all-party group. It has been an extremely well informed debate, and I look forward to reading it.
	In conclusion, I believe we have delivered much of what we could have been expected to deliver in the funding and organisation of social care for adults in this country. We have also placed a new emphasis on dignity for older people, on the need to develop advocacy and independence and on the need to enable them to make the proper choices for themselves, whether that is residential care, extra-care housing, intermediate care, or care in the community on which they can rely.
	The debate has been absolutely excellent. I hope that it has reassured noble Lords that our partnership with local government is strong and frank and that it is not only for the short term but will certainly see us through the Wanless processes as we meet those unprecedented challenges. I have no difficulty in saying in response to the letter in the Guardian today that we will work with local government to find a viable and lasting solution.

Lord Bruce-Lockhart: My Lords, I am grateful to the Minister for her reply. I very much agree with what she said. It has been a privilege for me to bepart of a debate that has had so many valuable, experienced and heartfelt contributions. I beg leave to withdraw the Motion for Papers.

Lord Hunt of Kings Heath: rose to move, That the draft regulations laid before the House on 15 November be approved [First Report from the Statutory Instruments Committee].

Lord Hunt of Kings Heath: My Lords, these regulations will among other things significantly extend the scope of the financial assistance scheme announced in May's White Paper, Security in Retirement: Towards a New Pensions System. This increases the Government's commitment to the FAS to £2.3 billion, and means that the FAS will now help about 40,000 people who have lost significant amounts of occupational pension.
	The regulations extend eligibility for the FAS to members of qualifying pension schemes who were within 15 years of their scheme's normal retirement age on 14 May 2004. Instead of helping only those who were within three years of normal retirement age, as before, the FAS will now top up to about 80 per cent the pensions of those who were within seven years of normal retirement age on 14 May 2004. Those between seven and 15 years from normal retirement age, who can more reasonably be expected to supplement their retirement income for the rest of their working lives, will be considered for a top-up to about 65 per cent of their expected core pension, and 50 per cent if they are between 12 and 15 years from their normal retirement age.
	Much criticism of the FAS has focused on the number of people whom we are currently paying. However, one reason for this is that the FAS payments normally begin at 65, so the vast majority of potentially eligible members have yet to attain this milestone. However, some people can join the FAS before 65, and they are expected to be among the first to benefit from the extended scheme. The terminally ill and survivors of those who would have been eligible under the extended scheme can be paid regardless of their age, and I expect that some widows will become eligible for consideration as soon as these regulations come into force. All being well, I expect we will begin to make payments to widows under these regulations before Christmas.
	The amendments we are proposing also bring additional schemes into the FAS. We have been made aware of some pension schemes that are currently excluded from the FAS because their employer has not had a formal UK insolvency event but that are, to all intents and purposes, insolvent. We are determined to ensure that schemes that meet all the rest of the FAS scheme's qualifying criteria are not excluded on a technicality.
	This is why these regulations will allow a scheme to qualify for the FAS where an overseas insolvency event substantially corresponds to one that the FAS already accepts in the UK for the purposes of qualification, or where the employer associated with a scheme has liabilities that exceed its assets and cannot pay its debts as they fall, or have fallen, due. In both cases, the scheme manager will need to be satisfied that the relevant employer is unlikely to continue as a going concern.
	These amendments demonstrate our desire to define insolvency as widely as possible in order to bring schemes and their members into the FAS. They do not affect our oft-stated belief that ongoing solvent employers remain responsible for making good their pension promises to members. As already touched on, the regulations also introduce a number of amendments linked to the calculation of FAS payments and additional review and appeal rights linked to the determination of terminal illness for FAS purposes. These regulations ensure that the FAS continues to operate effectively and provides assistance to more of those scheme members who face the most significant losses. In my view these regulations are compatible with the European Convention on Human Rights. I beg to move.
	Moved, That the draft regulations laid before the House on 15 November be approved [First Report from the Statutory Instruments Committee].—(Lord Hunt of Kings Heath.)

Lord Skelmersdale: My Lords, I am grateful to the Minister for explaining the regulations, which are beneficial to some—but only some—of the 125,000 people who, through no fault of their own, had no or little defined benefit occupational pension because their employers' scheme was underfunded when the latter became insolvent or no longer existed over the seven years before the Pension Protection Fund was set up.
	Noble Lords will remember that the financial assistance scheme was not originally in the 2004 Pensions Bill. I must confess that neither I nor the Minister led on that legislation although I did play a minor part. The Bill set up the Pension Protection Fund, but, after intense pressure from the Opposition and their own Back-Benchers, the Government gave in and created a very limited scheme which was to cost £400 million over 20 years. The trustees of the schemes were given a very limited time to apply; namely, between 1 September 2005 and 28 February 2006. Beneficiaries were to get financial assistance only if they were within three years of their normal retirement date. We described that as inadequate at the time and it seems that now the Government have finally agreed with us.
	To be fair, and I try to be fair on these occasions, the Government said at the time that they would review the scheme after three years. However, the scheme began operations—badly, as I shall explain—only in September last year. My first question is therefore: what brought on the earlier review, resulting in the regulations? Was it the Parliamentary Ombudsman's report on occupational pensions of March 2006, when she criticised the scheme? If so,the regulations are a very partial response. The Government still refuse to do anything about the real substance of her report, which was on the overzealous encouragement that the Government gave to pension schemes. She determined that it amounted to mis-selling.
	In July this year, the scheme faced further criticism for its inadequacy by the PAC, even though a month before, the noble Lord's colleague, the Minister for Pensions, had commissioned a review of the scheme. Almost at the same time as the PAC's report, the Minister revealed the findings of his administrative review, which cited a number of problems and recommended that it be governed from within the Pension Service. The Government have always said that it should operate separately from the Pension Protection Fund. So can the Minister say how and by whom it is administered? Or perhaps the question should be, "will be administered", especially as under the current scenario £7 million has already been wasted in setting it up, £1.25 million of which was on administrative staff. Some, too, has been given to the 550 successful claimants, but how much? The last figure I have obtained, which I find very difficult to believe, is just under £2 million, which seems far too high for so few recipients. Even if that figure is correct, what was the other £3.75 million spent on? Was it on yet another IT failure?
	As I said, about 125,000 people have lost some or part of their pension. However, as the Minister has just said, even this newly extended scheme is expected to benefit only 45,000 people, and even for them the prognosis is not good. So far, a mere 550 qualifying members have received any money, although under the current scheme about 7,800 people are or will be eligible to receive payments, as the Minister for Pensions explained in another place only a few months ago. In June, he expected that by now 5,000 people would have at least some money. Have they? I am sure that the Minister will be able to elucidate on that when he winds up.
	To sum up, on 22 October, an article in the Sunday Telegraph stated:
	"The Financial Assistance Scheme is a shameful example of political spin. It is based on false figures and has offered the tens of thousands of people who have lost their final-salary pensions little more than false promises and false hopes".
	The situation gets worse. In their response to the ombudsman's report, the Government said of the financial assistance scheme:
	"Eligibility has now been extended to people within fifteen years of their scheme pension age".
	At that point, surely it had not. That is what these regulations do. The response continued:
	"This involves tapers from 80 per cent of expected"—
	I highlight "expected"—
	"pension for those within seven years of their pension age, 65 per cent if between seven and eleven years, and fifty per cent for those between twelve and fifteen years",
	as, indeed, the Minister has just told us.
	At the same time, the Government appear to have invented a new concept in pensions—that of a "core pension", referred to in paragraph 7.11 of the Explanatory Notes. What is this? Is it higher or lower than expected pension benefits? To make all this even more complicated, the maximum any recipient can expect is 80 per cent of what they thought they would get—and even that is capped at £12,000. It is so complicated that, at this late hour, I would not be able to take in a verbal explanation. The Minister is probably relieved at my saying that but I would be grateful if he would provide me with a written explanation.
	However, as I said, these regulations are beneficial to some of the 125,000 unfortunate people involved in this mess—which has hardly been helped by the Government taking £5 billion a year out of the stock market over the past 10 years. Be that as it may, we welcome several things about these regulations. The first is the fact that an employer's overseas insolvency event should potentially be a qualifying insolvency. Secondly, we welcome the extension of the survivor's eligibility rules. It is certainly right that if a person's dependants were entitled to a pension under his employer's scheme when he died, that should be allowed under the FAS as well.
	I have already mentioned the complications around the extension of liability. Although I agree with the policy, I eagerly await the Minister's response to my dilemma. Interim pensions, too, must be the correct approach.
	Finally, I observed that in introducing these regulations in another place yesterday, the Minister began his remarks by wanting to express "yet again" his sympathy for all those who have lost out on their pensions through no fault of their own. What I have never heard from any Minister anywhere is any hint of apology for their part in the worsening situation of pensions in this country. In 10 years under this Government we have moved from the very top of the international league to the bottom, making defined benefit schemes rarer than hens' teeth. It is not a record to be proud of.

Lord Hunt of Kings Heath: My Lords, the noble Lord should not take that to be, or not to be. These matters will undoubtedly have to be decided in due course.
	We reckon that for the first three years of the FAS there will be about a £10.5 million start-up and running cost, which it is unfair to compare with the actual amounts to be paid out. It is also worth making the point that this exercise is costly because of the work in relation to the schemes, the information that has to be gained and the databases that have to be set up. Once that has been done, the cost of the FAS should then come down as it should be much more a paying-out operation, which is why it is then more suitable to be transferred into the Pension Service.
	The noble Lord made a number of other comments about the scheme. I think he implied, even though there is an extension to 15 years with tapering provisions, that it would not apply to all members affected by the failure of the schemes we are discussing. There is no question but that anyone who is concerned about pensions will feel the deepest sympathy for those affected by the failure of their pension schemes, but he will know—this was behind the original decisions about the FAS, and the basic philosophy remains the same—that there is a difficult balance to be drawn here between concern for the individual scheme members and the issue of how much the taxpayer can reasonably be expected to fund, bearing in mind that many taxpayers will not benefit from pension schemes even as generous as the contributions that the FAS will provide to scheme members.

Lord Hunt of Kings Heath: Of course, my Lords, but that would be the same for anyone receiving occupational pension schemes. Frankly, I do not believe that is a material point.
	I come now to the ombudsman's report, which the noble Lord mentioned. Again, we have debated this on a number of occasions. I do not think it would be fair or appropriate for taxpayers to bear the full cost of implementing the report, which we estimate at about £15 billion in cash terms. It seems to me that both the ombudsman and the Select Committee recognised in the report that it was not the Government who caused the schemes to fail. I remind the noble Lord that, of the leaflets that were part of the issue at the heart of the ombudsman's decisions, one of them was issued by his own Government in, I believe, 1995.
	The noble Lord, Lord Skelmersdale, cannot resist a discussion about advanced corporation tax. Once again he raises the figure of £5 billion. I remind him that the Government do not recognise that figure; I also remind him that the Pensions Policy Institute thought the figure was around £3.5 billion. Equally, one would have to say that, in relation to the impact on pension schemes, there were many other factorsas well, including the changes in the actuarial calculations on the years that people live. He will also recall the fall in the stock market during that period that was greater than these figures—even if we accept the £5 billion, which I do not. I also remind the noble Lord that it is this Government who, through the PPF and the FAS, have provided and are providing much greater security for members of pension schemes.
	In conclusion, of course I recognise that the extension to the scheme that these regulations bring will be very important to many people. We are very concerned to ensure that the scheme is administered as effectively and efficiently as possible. We depend on the co-operation of trustees. I believe that we are now working effectively together with the trustees but we will continue to say that where information is not being provided, it is very important that trustees and administrators provide it to make the scheme work as effectively and quickly as possible.

Lord Evans of Temple Guiting: rose to move, That the draft order laid before the House on 28 November be approved [Third Report from the Statutory Instruments Committee].

Lord Evans of Temple Guiting: My Lords, the Government wish to present the modifications to the definitionof a British film contained in Schedule 1 to the Films Act 1985 made by this draft order. These modifications have come as a result of discussions with the European Commission, and it is essential that they are made to ensure that aid given to film through the new tax reliefs is compatible with European law on state aid. That is the purpose of the order.
	As we stated in March of this year when the House approved the original cultural test, it remains our aim to promote the sustainable production of culturally British films, ensuring that films continue to playan important role in British life, representing and reflecting British culture in its most diverse sense. To do this, the Chancellor confirmed in yesterday's Pre-Budget Report a generous new tax relief, available to those films certified as British by the Department for Culture, Media and Sport, against the criteria I will outline today.
	The original cultural test, introduced in April 2006, contained three categories for assessing the cultural benefit of a film: the cultural content, hubs and practitioners—in other words, what the film is about, what facilities were used in making it and the personnel who made it. The revised test we are debating adds a fourth category of cultural contribution. This category ensures that films which contribute to British culture in its widest sense will be able to be awarded points under the test. The revised test also shifts the weighting of the sections towards cultural content, rather than focusing on film-making elements. These modifications will ensure that the aid given is compatible with the rules on state aid. The revised test will not impose any extra burden on the film industry or the Civil Service. In fact, it should be less time-consuming and burdensome for film-makers to complete.
	The department carried out a full 12-week consultation on the existing cultural test in 2005, and developed and published the guidance on it in response to views expressed in that exercise. In drafting this order to implement the revised cultural test, we consulted with HM Treasury, HM Revenue and Customs and the UK Film Council.
	To pass the revised cultural test, a film will require 16 points out of a possible 31. There are four sections to the test. The first section assesses whether the content of the film is British against the following criteria. Up to four points will be awarded depending on how much of the film is set in the UK, or a representation of the UK. Up to four points will be awarded depending on the number of lead characters who are British. Four points will be awarded if the subject matter or the underlying material is British. Finally, up to four points will be awarded depending on how much of the film is in English, or in a recognised regional or minority language.
	In the second section, up to four points may be awarded in respect of the contribution to British culture made by the film. This section was introduced to give the test flexibility to reward contributions that a film may make by reflecting or representing British culture in its widest sense. This section will assess films under the following three headings: creativity, cultural heritage and cultural diversity.
	Up to three points will be awarded in the third section, cultural hubs, depending on the amount of film-making work that takes place in the UK. Finally, up to eight points will be awarded in the fourth section—cultural practitioners—depending on whether the personnel involved in making the film are British nationals or residents, or nationals or residents of the member states of the European Economic Area.
	There is one exception to the 16-point pass mark. Where a film scores all four points for being in English, and all available points in the cultural hubs and cultural practitioners sections—that is a total of 15 points—it must then score at least two points in one of the remaining parts of the cultural content section. This exception arose to address the European Commission's concern that a film that achieved these 15 points, which do not reflect the purely cultural content aspects of film-making, could qualify with a minimal amount of British cultural content.
	Noble Lords will be interested to learn whether some of the most iconic films would have passed such a test. A whole raft of undeniably British films such as the "Charlie and the Chocolate Factory" and "The Constant Gardener" would do so because of their relevance to British culture.
	We will offer a system of interim approval for films applying under the test. The film industry is particularly keen on this, because it will offer more certainty to film-makers and help them to secure financing for their films. DCMS officials will also offer advice and assistance to film-makers when filling out the application form.
	The revised test will come into force on 1 January 2007. All films which commence principal photography after this date will be required to pass the test to be eligible for new film tax relief. In addition, the Treasury will make regulations under the Finance Act 2006 to provide that any film which commences principal photography before 1 January and is completed after this date, and passes the revised cultural test, will also be eligible for the new tax relief. I commend the order to the House. I beg to move.
	Moved, That the draft order laid before the House on 28 November be approved [Third Report from the Statutory Instruments Committee].—(Lord Evans of Temple Guiting.)

Lord Clement-Jones: My Lords, I thank the Minister for his speedy introduction to the order. I welcome the confirmation in yesterday's Pre-Budget Report of the commencement of the film tax credit on 1 January. I am sure that that will be welcomed by the film industry.
	It has not been an altogether happy situation during the past few years, with one tax relief being terminated two years ago and a new one only now being put into place. We have had considerable uncertainty during that period, partly as a result of delay in agreeing the new culture test with the European Commission.
	We know that the test which was originally put forward earlier this year was not acceptable. One of the real issues is defining British culture. I suppose that that has required energy and time. The Minister set out the various categories of the British culture test.
	One key concern is the considerable switch that has been made from a number of economic tests towards a more cultural test. The key to the tax credit being proposed by the Government must surely be to ensure a viable, vibrant and creative UK film industry, with facilities being provided in this country. A huge number of companies are affected, as the RIA states, and there is a question whether we may not have swung the balance too far towards a pure cultural test and away from the benefits gained by the previous test.
	The impact of the new test is interesting. The cultural content is considerably increased, but the cultural hubs have been reduced to three points in this new system. The location of principal photography, editing and so on has become much less importantin the new test. The weight placed on cultural practitioners—that is, on the personnel making the film—is less. Then there is the whole issue of the new cultural contribution, which is included. I am exercised by the fact that the noble Lord, Lord Davies of Oldham, when he introduced the previous order which had the previous British film test in it, said:
	"The fact that 15 of the points are allocated to where the film is made is a response to the overwhelming view from consultation respondees that greater weight should be given to this section than to the others, so as to incentivise the use of UK talent and facilities and to build a sustainable British infrastructure for film making. Visual effects, in particular, are eligible for more points, as this is the biggest below-the-line spend for large budget feature films, and the UK's facilities are world leading and need to be incentivised to meet increasing competition from overseas".—[Official Report, 30/3/06;cols. 925-26.]
	I do not necessarily have the answers to this, but that was a clear statement by the Minister on the benefits of the previous test, which are not included in this test, which is the one that the Government have effectively negotiated with the European Commission. Are we potentially undermining our film industry by giving too much emphasis to the current system—the current culture points—and too little to where the film is made? There is also the question of how the new system interacts with the expenditure test and how it will work when the culture test is administered by the DCMS and the expenditure test is carried out by the Treasury. The Explanatory Memorandum tries to reassure us that it will be a seamless process, but could the Minister give some indication as to how it would work?
	Many of those in the industry have welcomed the pre-certification arrangements, which is very helpful, and the post-implementation review will also be welcome. Who will carry that out when the time comes in two years from 1 January 2007?
	We are always reasonable when dealing with Brussels and, no doubt, these negotiations have been fairly tough but amicable, but how do our incentives actually compare to those in other EU countries? Did the Government actually undertake a comparative study? The acid test is whether our film industry will be incentivised and supported by the new credits. The Minister mentioned a couple of films that would still go ahead, and it is helpful to get that sort of indication; but in practice it is important to see whether certain films fall into those categories. Will "Harry Potter and the Goblet of Fire" or "The English Patient" fall within the culture test? The answer is probably, in the first case and perhaps, in the second case. What about "Death in Venice"? Looking back, the answer to whether that would be included is probably not. This will boil down to what happens in practice, but I very much hope that the Government will carry out their post-implementation review rigorously. I also hope that it is carried out in co-ordination with the film industry, which has a great deal at stake with regard to the new order. These Benches wish it well.

Lord Howarth of Newport: asked Her Majesty's Government what plans they have to increase support for the conservation of historic places of worship.
	The noble Lord said : My Lords:
	"Still they stand, the churches of England, their towers grey above billowing globes of elm trees, the red cross of St George flying over their battlements, the duplex envelope system employed for collections, school mistress at the organ, tortoise stove slowly consuming its ration, as the familiar seventeenth century phrases come echoing down arcades of ancient stone".
	John Betjeman wrote those words in the introduction to the Collins Guide to the Parish Churches of England and Wales in 1958. In the half-century since then, the elms have gone, and the cross of St George has become more readily associated with the new national religion of football. My right reverend informant tells me that the duplex system has fallen into desuetude. The flat prose of the late 20th century has replaced 17th-century cadences. While the churches of England mainly still stand, between 1970 and 2004 the Church of England closed some 1,630, and 85 listed churches were actually demolished. The churches that continue to stand defy financial gravity.
	In a predominantly secular age, when innovation is our public watchword, why should it matter to us that our heritage of historic places of worship of all faiths should be conserved? It is a question of respect; another of our watchwords. As Simon Jenkins, the latter-day laureate of churches, wrote in England's Thousand Best Churches:
	"Into these churches Englishmen and women have for centuries poured their faith, joy, sorrow, labour and love ... The church marked each event in life's calendar ... It was a patron of community ceremonial [and] a gallery of vernacular art".
	The physical manifestation of the church, more often a cumulative creation than a single expression of architecture and design, with its carving in wood and stone, wall paintings and altarpieces, stained glass, brass and iron work, tiles, embroidery, books, language, its music and bells, its whole ritual and life for centuries has met profound human needs, which we no longer know very well how to meet in communal life. These places remain however, for unbelievers too, landmarks and centres and symbols of communal identity. In 2003, 86 per cent of the population visited a church. Some 24 per cent of city dwellers said that they went into a church to find a place in which to be quiet.
	The beauty of this holiness is recorded and exhibited not only in Simon Jenkins's book but in two wonderful volumes published this year. One is A Glimpse of Heaven, with a learned text by Christopher Martin and glorious photographs by Alex Ramsay, which displays a heritage of Roman Catholic churches that has been too little appreciated, not least, as English Heritage acknowledges, in the statutory listing system. In Jewish Heritage in England: An Architectural Guide, Doctor Sharman Kadish documents historic synagogues and Jewish cemeteries. The former Spitalfields Great Synagogue was originally a Huguenot, then a Wesleyan place of worship. It is now the London Jamia mosque. As Doctor Kadish says, it encapsulates on a single site the immigrant history of east London.
	There are 16,151 Church of England parish churches in England—more churches than there are petrol stations, as has been noted by Mr Trevor Cooper, chairman of the council of the Ecclesiological Society. Some 13,000 are listed; 4,000 in grade 1 and another 4,000 in grade 2*. Some 45 per cent of all grade 1 listed buildings are Church of England parish churches. In England, there are 3,465 Catholic parish churches, other churches and chapels, and 625 are listed. There are 5,312 Methodist chapels, of which 541 are listed. There are 1,115 United Reformed churches, of which 290 are listed, and 1,809 Baptist churches, with 283 listed. There are 30 listed synagogues. One purpose-built mosque has been listed. A number of others are in historic buildings already listed.
	Some £70 million of funding for major repairs to historic places of worship is raised by local congregations. There are 31 county historic churches trusts. The noble Lord, Lord Lloyd-Webber, I hope, will tell us about the Open Churches Trust, which he has founded. A great deal of private generosity and intelligent self-help goes on. For instance, central Norwich, where I live, contains 32 medieval parish churches, which is the largest surviving group in northern Europe. The Norwich Historic Churches Trust, which my noble and special friend Lady Hollis of Heigham was instrumental in establishing, has found innovative uses for 18 redundant churches, including the puppet theatre housed in St James, Whitefriars, and a martial arts centre in St Peter, Parmentergate.
	Since 2004, the Norwich Heritage Economic and Regeneration Trust, HEART, which has just invited me to serve on its board, has sought to bring together all the churches to explore the advantages of caring for them as a group. Working groups have been set up to bring together the clergy, trusts, the council and others. Funding from the East of England Development Agency has made possible a major study of how the whole set of churches can be made financially sustainable, play their part in the local economy, be educationally inspiring and be fully available to the community and visitors.
	There are large uncertainties over the future of some churches that are among the most important in the heritage. Of churches illustrated in A Glimpse of Heaven, St Walburge, Preston, a grade 1 listed building and a vast 19th-century church with the tallest spire of any parish church in Britain, is stranded in an area of urban deprivation, while the diocese is having to consider closing churches. The Government have recognised such difficulties and have done much to help. In their response in October to the Select Committee report Protecting and Preserving our Heritage, they stated in terms:
	"The Government is committed to keeping the country's historic churches in a good state of repair".
	DCMS Ministers need no persuading of the importance of the heritage of historic places of worship. That was made clear in Mr David Lammy's response to the debate in another place on 17 May.
	Funding from government and lottery sources will total around £60 million this year. The Listed Places Of Worship Grant Scheme, which returns the VAT paid on repairs to listed places of worship, provides an average of £1 million a month. The Chancellor announced in the Budget that the scheme would continue until 2011 and would be extended to cover professional fees and repairs to clocks, pews, bells and organs. The joint repair scheme for places of worship, run by English Heritage and the Heritage Lottery Fund together, has paid more than £90 million since it began. This week, Dame Liz Forgan has announced that the HLF has agreed a dedicated funding programme for places of worship costing some£20 million a year from 2008 to 2013—a difficult period for the fund.
	Support for appropriate new uses for the redundant places of worship in their care is an important element in the work of the Churches Conservation Trust and the Historic Chapels Trust. The CCT, which receives half of its funds from the DCMS and a quarter from the Church of England, now cares for 338 historic churches of distinction. Five more churches, all listed in grade 1, have been added to the CCT's portfolio in the past year, although the DCMS grant to the trust has remained fixed in cash terms since 2001. Some 206 visits to CCT churches were made in 2005-06 by schools and adult education groups. The Historic Chapels Trust, which has a smaller portfolio of non-conformist chapels, Roman Catholic churches, synagogues and private Anglican chapels, redundant as places of worship but of architectural distinction, received 70 per cent of its funding from English Heritage—and I look forward to the speech of the noble Lord, Lord Shutt of Greetland, who is a trustee of the Historic Chapels Trust.
	Many historic places of worship are in good condition, but the burden of repairs on many other churches is heavy. With the need to support the stipends and pensions of the clergy, there is always a temptation for congregations to defer maintenance work and thus store up expensive future trouble. English Heritage considers that many of England's historic places of worship are approaching a critical time in their lives. Current annual spending from all sources on major repairs to historic places of worship stood at around £115 million in 2004, with a further £19 million spent on Church of England cathedrals, where much has been achieved in recent years. But that is not enough.
	The joint English Heritage-Heritage Lottery Fund repair grant scheme receives applications for twice as much as it is able to disburse. English Heritage's fabric needs survey indicates that the cost of the repairsthat ought to be done in the next five years would be £925 million, or £185 million a year. The gap between that £185 million and the total funds raised by congregations and contributed from the lottery and public sources is approximately £82 million. So what is to be done?
	As noble Lords know well, English Heritage has issued call to arms, Inspired!—a call not only to government but to the denominations and the general public. It is a call to all of us to think afresh about respective responsibilities, ranging from the person of modest means who sweeps the church in the true spirit of George Herbert, to the millionaire who resides in the Old Rectory, who might be a generous donor, but, equally, might assume that the parish church is just part of some eternal dispensation.
	English Heritage has proposed a fivefold strategy, to be funded by a package of government support costing £8.84 million a year for three years. A one-off sum of £2.52 million would enable English Heritage to rewrite outdated list descriptions for all grade 1 listed places of worship as part of the current reform of heritage protection. The purpose here is to help congregations to understand the value and significance of the historic fabric in their care and so to make better decisions. A sum of £2 million a year for three years would help to build congregations' capacity to manage their repair and adaptation projects. The main element here would be the creation of 15 full-time historic places of worship support officer posts. A sum of £4 million for three years would fund a new maintenance grant programme to help struggling congregations to reduce their major repair bills in the longer term. English Heritage wants to place alongside the English Heritage/HLF grant scheme for major repairs a new small-grant scheme. An extra £4 million for three years would double the number of repair projects supported over the next three years. Finally, English Heritage is asking the Government for some increase in funding for the Churches Conservation Trust and the Historic Chapels Trust as important safety nets.
	English Heritage is not asking the Government to shoulder all the responsibility and pay for everything. The proposition is that the very modest additional expenditure by the Government of £26.52 million over three years would enable us to move intelligently and decisively in the right direction. This strategy seems to me to be modest but realistic and incontrovertibly worth while.
	As Dr Simon Thurley, chief executive of English Heritage, has said,
	"the key to long-term security for historic places of worship will be about understanding the nature of the problem properly, tackling it rationally and methodically, yes partly through more money, but also by helping people on the ground to help themselves by offering support and expertise where it is most needed".
	As David Lammy said on 17 May,
	"we need an effective partnership between government, church denominations, heritage specialists and the public".—[Official Report, Commons, 17/5/06; col. 301WH.]
	I look forward to the Minister explaining to us what the Government consider that should mean.

Lord Lloyd-Webber: My Lords, I thank the noble Lord, Lord Howarth, for instigating a debate which is very close to my heart. I declare an interest on two counts. I love British churches, and I am the founder of the Open Churches Trust, whose aim has been to keep locked churches open. Probably all of us here have a love of the Pevsner volumes and remember Nikolaus Pevsner saying that there would have been no point in writing some of the volumes if churches had been locked—his work would have been over. That inspired me to found a trust to keep them open. When I started, two in five churches in Britain were open, compared with four in five now.
	I think that that is relevant to the debate because we cannot expect the Government to fund everything to do with churches. We know that local communities and parishes have a responsibility there. We also know that certain local parishes are unable to do that because they have ageing communities, and help is probably required there.
	Perhaps I may give some examples from the experience of the Open Churches Trust. I apologise for reading from notes, but I think that what I say may point a way forward. A wonderful example isSt Agnes at Sefton Park in Liverpool—a gorgeous church by Pearson. My trust gave financial help to keep it open, and we were most proud of that. AtSt George's in Cullercoats, Northumberland, we had to provide a security system. The difference is that at St Agnes, Sefton Park, we got local schools involved, whereas that was not possible at St George's. AtSt Andrew in Gretton, we got advice for walkers on how to get to the church, and at St Alfrege in Greenwich, which is next door to the Millennium Dome, dome or not, we got 36,000 visitors in the millennium year.
	That is by way of saying that I think that the Government can create a climate. It would be fantastic if they were able to suggest to dioceses around the country that support be provided by someone from a central area who could advise on how to raise funds for churches. I am not expecting the Government to do it, except maybe on specific occasions when a community cannot, but would it not be wonderful if the Government were to say, "We will make the wherewithal available for someone to go through the various ways—not just for the Church of England, but for other areas—to fund things"? That is what we found with the Open Churches Trust. We discovered that we do not need to fund most of the churches that are open. If that were possible, the debate would be thrilling. It would be wonderful if the Government felt that help was possible.

The Lord Bishop of London: My Lords, I declare a substantial interest as chairman of the church buildings division of the Church of England. I admire the work of the Historic Chapels Trust. I am in touch with colleagues in the Roman Catholic Church and friends at the Jewish synagogue listed in west London, which I visited on Monday. The Church of England, however, is responsible for 80 per cent of the listed places of worship in this country, so your Lordships can see why I can hardly be described, in that delightful American phrase, as a "non-remunerated endorser" of the case that the noble Lord, Lord Howarth of Newport, is making.
	We had a helpful description of the present financial regime from the noble Lord, Lord Howarth. Of the money spent on repairs each year, 70 per cent is generated by the local community and parish volunteers, so I do not recognise the somewhat elegiac picture sometimes given of these churches. A huge amount of flourishing community life is centred on chapels and other places of worship. The volunteers make heroic efforts and, in consequence, many churches are in a very good state, but there is still an annual funding shortfall for necessary repairs, exclusive of developments, which we estimate at about £54 million. I think the noble Lord's figure was rather more.
	English Heritage makes a very important contribution, particularly through advice and expertise. We entirely support the aims of the "Inspired!" campaign, but the modest sums being asked for reflect realism about the likely scale of funding for heritage, especially with the Olympic Games in view. At present, English Heritage makes a valuable targeted contribution of 6 per cent to the actual amount spent on the annual repair bill, and we devoutly hope that it will be able to continue support at at least that level.
	However, as the debate in your Lordships' House during the passage of the then Licensing Bill demonstrated, and as the speech of the noble Lord has just indicated, it would be a mistake to consign places of worship—churches—to the heritage category alone, and heritage finance cannot cover the real cost of maintaining historic places of worship as assets for the whole community. There are now more churches than post offices. There is abundant hard evidence of the contribution those buildings make to volunteering and cultural life in communities up and down the land. Churches and places of worship need to be considered as part of the way in which Governments achieve objectives that we all have at heart in the fields of social regeneration and education, and in subjects ranging from choral music to the preservation of craft skills. Churches and cathedrals also make a major contribution to the tourist industry and to local economies, yet that reality and potential is so often edited out when development and educational budgets are discussed.
	If you go to the family life centre in Angell Town, Brixton, where the young gather in their pre-school nursery in St John's Church, or visit the facilities for the elderly in St Leonard's, Bilston, you will see government policy for the young and the old being made possible by the use of a stock of church buildings that it would take riches beyond the dreams of Croesus to replicate today. We produced a discussion paper, Funding of Church Buildings: Next Steps, which invited Members of Parliament to contribute to the debate on the funding of our places of worship. Shortage of time prevents me laying out those proposals in detail, but I hope that any noble Lord who would value a briefing will not hesitate to demand one.
	Various things have already emerged. Many of the avenues for increased support that we have suggested are especially relevant to the inner urban scene and, of course, the challenge is particularly acute in rural areas. But even there there are encouraging developments that suggest that given a more flexible and equitable attitude on the part of those who control existing budgets, we could redress the asymmetrical relationship between private and public support for these community assets. The success of the solar panels on St Aldhelm's church hall in Edmonton has filled me with enthusiasm and opened up a fresh possibility. The many children who, every day, use the hall can see a digital display which shows how much their church is putting into the National Grid. Who will help us design cheaper and more beautiful technology so that places of worship countrywide can reflect the light of the Sun and transform it into energy for the common good? We need some fresh thinking in this area.
	In response to Funding of Church Buildings: Next Steps, I received a useful and critical letter asking why the Church of England did not rationalise its stock of buildings like the post office and dispose of the rural surplus. That takes us to the heart of a common, major misunderstanding. The Church of England is a devolved and thoroughly non-conformist institution. The Church Commissioners, whose board I chair, do not own the buildings, which are in the keeping of the local parish and community. That has insulated us against gusts of planning fashion, thank goodness, and has generated astonishing levels of generosity and hard work. Simon Thurley wisely said that it would lead to disaster to interfere with that passionately felt sense of local ownership. But it does mean that any national policy has to proceed by persuasion and incentives.
	The reality is that church buildings are used and valued as community assets by a huge proportion of the population, irrespective of their personal faith. They are cultural centres and depositories for the memories of the local community.
	For me churches are sacred places which robe our destinies in stone—I do not want to conceal that truth from your Lordships—but that is not the basis for the church's and the chapel's appeal for the support of public authority. Places of worship are oxygenating plants in our social life. If we are interested in social cohesion, the mosques in east London as well as the churches of Manchester play a vital part. Clear and articulate public recognition of this fact would be an important prelude to responding positively to the plea made by the noble Lord in his opening speech.
	Our aim should be a symmetrical relationship between volunteer effort and public funding with50 per cent of funding for repairs to listed churches coming from public sources of various kinds, existing budgets being opened up to accommodate this, and with places of worship having equal access to development budgets without any prejudice against them as somehow being connected with "faith groups".

Lord Griffiths of Burry Port: My Lords, I add one non-conformist's support to what I now understand is another non-conformist in the efforts to consentise this Chamber to the needs of this important aspect of our national heritage.
	I stand here as one who by the right reverend Prelate the Bishop of London was helped to become a canon of St Paul's Cathedral and also a member of the cathedral council, which has given a rare opportunity to me as a Methodist minister to see from the inside how some of the questions that have been alluded to here are faced on a regular basis.
	There has been a massive refurbishment of the cathedral over the past five or six years costing£30 million. It has transformed the cathedral. It was already not only a national asset but a national icon. But it has surpassed all its previous standards and we see it as we have never seen it before. The skills of those who put the finances together to achieve this refurbishment are considerable.
	St Paul's Cathedral stands at the heart of the City of London. Therefore, accessible to those seeking money are avenues to explore that do not exist for everybody, shall we say. At the same time the combination of church-generated funds and funds sought from the local community—admittedly a rather exceptional local community in this case—have achieved this extraordinary accomplishment.
	I have noticed in looking at the revenue spending of the cathedral just how dependent it is on visitor numbers. Eighty-two per cent of its revenue costs depend on how many people pass through the doors. When national events require the floor of the cathedral, the loss to the cathedral revenue is considerable. I suspect that that aspect is rarely thought about.
	When we have a 9/11 or a 7/7, the impact on the cathedral's everyday life is very considerable indeed. We had to watch, for example, an extraordinary educational programme by the St Paul's Institute cut back very severely for two or three years until visitor numbers were regenerated. The educational programme was not aimed specifically at the worshipping congregation, but at all those people working in the City of London. The community dimension, the asset to the City of London and to our national life represented by the cathedral, has to be borne in mind when we look at the questions before us today.
	I am also the superintendent minister of a Grade I listed building, Wesley's Chapel, built by John Wesley. The same architect designed the Mansion House and other significant buildings in the City of London. We have a very vibrant and growing congregation and we have never claimed a penny from public funds for anything. We have always paid our own bills. I come from an ethos where paying clergy, dealing with the programme costs and refurbishing and maintaining buildings has always been something to be faced by the local congregation. I am proud to say that that is the case.
	In my office at City Road, I regularly see representatives from the large majority of the 50 or so national charities headquartered within a mile of us who come to use our space for one meeting or another. That is a regular occurrence. I see Muslim children coming two by two from schools in the East End of London to acclimatise themselves to how Christians go about their ordinary devotional tasks. During Ramadan, people from local offices came to ask whether, as there was not space in their offices for them to say their prayers, they could say them in our space. We were delighted to accommodate them.
	We have an opportunity by contributing space such as that which I manage and am responsible for to contribute to the national well-being and the creation of a new climate in which to address some of the very contentious questions that we face in contemporary society. We do not threaten people, but give them the opportunity to consider those questions openly.
	I know that one day, the coping stone will fall off; one day, I know, a bit of a moulded ceiling—our Adams-type ceiling—will fall on our worshippers. One day, I know, we will not be able to generate the funds that we need to keep the building in the state in which it needs to be kept. We have never appealed to anyone beyond ourselves before; but, one day, I know that we shall.
	English Heritage has played a significant part in the life of Wesley's Chapel, but let me tell you what it is. When we find a crack in a piece of York stone, English Heritage does not allow us to make a quick-fix reparation. We have to get another bit of York stone to replace the one that has cracked. That is hugely expensive. One day, I know, I shall be obliged to go cap in hand to English Heritage to say, "Your turn now".
	I recognise the combination of resources that must be brought together. We are looking for a new dean for St Paul's Cathedral. I suspect that we will be looking for someone with entrepreneurial rather than spiritual skills in order to keep on finding the money to face those obligations. I wish that that were not the case. The right reverend Prelate the Bishop of London can perhaps reassure me, but I am sure that noble Lords will see my point. Surely we must keep our space open. There must be a combination of funding from the worshippers and the locality and a responsible attitude to redundant buildings—that the resources released from their sale may be put to restoration costs—but, in the end, we will look beyond those possibilities to the state.
	That is a rounded view of the matter and I suspect that my noble friend Lord Howarth, to whom I offer my thanks for initiating the debate, will want to press the Minister to answer those questions.

Lord Roberts of Llandudno: My Lords, this is indeed a notable day in the history of the House of Lords—possibly even historic. Never before have two Welsh Methodist ministers spoken following each other in this Chamber—and between two Bishops. What a notable day it is. It is most ecumenical.
	I was tempted to ask: what is an historic church? I love the churches that we visit—Lincoln Cathedral and other places. I love the majesty of those buildings. You look at the awe-inspiring interiors, the soaring steeples and, in some places, majestic domes, and you say, "This is a wonderful place". But in Wales, as in rural England, I guess, we have different historic buildings. The structure may not compare with that of the big cathedrals and religious buildings in Wales,as well as in England. You might come from Aberystwyth to a little chapel at Tre'r-ddol, significant because the Welsh revival of 1859 began there. Unfortunately, Tre'r-ddol chapel is now closed. You might then come to the Conwy Valley, where you would see Penmachno, which I imagine all noble Lords will know. Bishop William Morgan lived there at Ty Mawr Wybrnant when he translated the Bible into Welsh in 1588. The Anglican church is there, but that is also closed.
	You might then go to Eglwysbach, which is still open but struggling a wee bit, where John Evans, the giant of the Welsh pulpit in the century before last, was brought up and inspired so many people. You will pass place after place, such as a little chapel at Fforddlas, where Begi Owen, the mother of non-conformity in much of north Wales, came from and worshipped. These chapels are now in danger. Some are already closed, and many more are threatened with closure. The number attending is small. A small number of people struggle on to keep their particular place of worship going. I would call many of these people saints, as they give so much in every denomination. The insurance premium for one chapel used to be about £800 a year. If it has four members, they somehow need to raise £200 a head just for that insurance premium.
	Then there is the maintenance of places. The smaller the numbers, the more difficult it is for them, until sometimes you are left with three or four ageing people. They are saints, yes, but they suddenly feel that they cannot continue. The secretary retires and the treasurer moves into an old people's home. All those sorts of things happen, and suddenly that chapel closes. Some of them would unite with another chapel, although that is not always easy. I have gone white trying to unite chapels in parts of Wales. Some will say that they have struggled year after year and do not want to give up their little chapel. You can respect them, even though you try to suggest that they channel their energies, or whatever is left of them, in a different direction.
	We need money, as everyone has said. Perhaps Cadw, the Welsh equivalent of English Heritage, will also be able to help in that direction. However, we often need people more than pounds. A little group of people might not really have anyone to look after the finances. Could we not organise it so that someone could come from outside and give the necessary help in that place?
	Then there is the question of property and the weather. We have had gale-force winds even in London in the past couple of days, and the tiles have come off the roof. Mrs Roberts or Mrs Jones cannot climb up on the roof to put a tile back. We need help for property—someone from outside to join the four or five local church members to give them confidence and the help that they need. As I said, we need people as well as pounds. I suggest again very briefly that we could have a partnership—I have mentioned this before in the Chamber—between well resourced and well attended churches that could adopt a chapel or church in their vicinity as part of an adopt-a-chapel scheme. One or two of their people might be willing to go there to help to keep the finances in order and to see that those slates go back on the roof. We know that ministers are in short supply in every denomination. One minister cannot really attend to everything. Is it possible to think of a helpline for small churches and chapels, or an office to which we could go to say, "There is a flood in our grounds. Can you come in and give us some sort of help?"? Could we, as an ecumenical body, establish that facility to help those who are in trouble, cannot attend to the problem or need a hand? With these suggestions, I would ask the Government to help us financially but also help us to come together and to share these ideas. I am sure that the people, as well as the pounds, will help us in the future.

The Lord Bishop of Southwell and Nottingham: My Lords, I too thank the noble Lord, Lord Howarth, for initiating this debate. I speak not only as a bishop of the Church of England but as chairman of the Churches Main Committee, which represents some40 Christian denominations to the Government, particularly on legislative proposals affecting churches. With the increased understanding of 20th-century architecture and vernacular architecture, more non-Church of England churches may be listed in future. It is very good to see that the DCMS and English Heritage are increasingly realising the role that an apparently modest Cornish chapel, for example, can serve in the community.
	So I too am concerned about the need for funding and the shortfall between the amount spent on repairs and that which needs to be spent. Without churches, central and local government could not deliver many of their worthwhile objectives. It is not unreasonable to ask for further financial help to ensure that the buildings that provide these services can be properly repaired and maintained to the high standards that informed conservation rightly demands.
	I wish to stress the community benefit, which others have touched on, and the church's desire to share in this work of serving the whole community. We have a long tradition. Our hospitals, schoolsand many social services spring from provision first made by many churches. Church buildings of all denominations and those of other faiths increasingly provide a base from which these activities can be carried out and, as the noble Lord, Lord Roberts of Llandudno, hinted, the people to provide them.
	In my diocese of Southwell and Nottingham, where 21 of our parishes are among the 10 per cent most deprived areas in England, 85 churches offer parental support in the form of toddler groups; 80 churches offer drop-in, lunch and other facilities for elderly and retired people; 26 churches, in a practical way, work with homeless people; 13 churches work with refugee and asylum seekers; 26 churches work with offenders, ex-offenders and their families; and 22 churches support people with drug and alcohol problems. If those volunteers had to be paid, even at the minimum wage, the effect on the public purse would be considerable. In Yorkshire alone, it was estimated in 2002 that the value of social work voluntarily carried out by church communities was between £55 million and £75 million a year, which is more than the annual shortfall we estimate on repairs to Church of England buildings.
	Our emphasis today is on support for historic places of worship. These churches also embody the living nature of the historic environment. Over the past 20 years, there has been an increasing recognition that buildings are best preserved if they are loved, looked after and maintained by willing owners and that adaptation by an owner who cares for the building is better than preservation unchanged but lacking use. In almost every community the oldest, most complex and most interesting building still in its original use is likely to be the church.
	The Church of England, the Church in Wales, the Roman Catholic Church, the United Reform Church, the Methodist Church and the Baptist Union of Great Britain all benefit from what is often misnamed the ecclesiastical exemption. All have a comprehensive system of control over their own buildings which balances the needs of care and conservation with the prime purpose of places of worship as centres of worship and mission. We are conscious of the responsibility that that places on each of these churches. It was good news last year when the Government firmly accepted that the exemption should continue and gave it their confidence. We now look forward to the DCMS proposals for changing the heritage protection regime and hope that the exemption arrangements will receive an equal vote of confidence in those proposals. But no system is perfect, and congregations, like virtually all building owners, are anxious to see simplification, an issue raised by the noble Lord, Lord Shutt. The Church of England is working with English Heritage and local partners in two cathedrals, Canterburyand Rochester, and in one deanery, Taunton, to see how we can work together to simplify the different consents and develop a more streamlined, user-friendly framework.
	One further change due to take effect early next year is the Pastoral (Amendment) Measure under which a Church of England church can lease part of its building for other purposes. Previously that could be done only by making the church partially redundant, giving the negative if erroneous message that the church was closing. This new procedure will enable many churches literally to open their doors to good community uses while remaining places of worship. That canonly help the increased sense of partnership that we wish to develop for the good of our buildings and communities.
	I believe that in 50 to 100 years' time history will judge us harshly and we will perhaps not be forgiven if, in our generation, we have failed to secure our wonderful heritage of historic places of worship and not enabled them to remain, as they always have been, vibrant places at the very heart of our communities.I hope the Minister will give the House some encouragement in his response.

Lord Harrison: My Lords, on Monday, my NHS chiropodist showed me a newspaper cartoon depicting a man fleeing a high street festooned with seasonal bunting, entering a church and saying to the surprised vicar, "Can I shelter in your church, vicar? I'm trying to escape Christmas". That cartoon accurately illustrates today's debate. In the face of dwindling congregations and diminishing resources, how do we fill our church buildings again and how do we find the resources to repair, maintain, adapt and update our magnificent stock of churches and cathedrals serving local communities?
	I, too, am grateful to my noble friend Lord Howarth of Newport for taking up the theme of a debate that I moved some two years ago in your Lordships' House and for so gracefully introducing his debate tonight. I am also grateful for English Heritage's Inspired! and for the Church of England's Funding of Church Buildings: the Next Steps, which rightly asserts that the church—the right reverend Prelate the Bishop of London repeated it today—is asking for money not for its mission but for its buildings. The latter is a well argued and welcome document but has some lapses in the evidence presented. For instance, you cannot compare cinema numbers with the numbers of those who come to church. In the one instance people are paying; in the second, some of those coming are attending family births, marriages or deaths.
	A further shortcoming is that both documents understandably concern themselves with five-year plans for repairs and attempts to recover the situation and stabilise the problem, but we desperately need longer-term thinking and plans. We need to be much more imaginative about sources of funding and the complementary uses that churches and church buildings might be put to. In developing these longer-term plans the central criterion is the need to maintain sustainable communities, with church and non-church-related activities taking advantage of church buildings which are so often located at the heart of viable or revivable local communities.
	I suggest that three interested parties are needed to develop this long-term planning. The first is the overwhelming majority of citizens who, like me, do not go to the local church—I include myself as a loyal member of God's opposition. We gazers-on from the outside must wake up and get stuck in to save our local churches from falling apart by actively participating in local support groups, supporting local funding or consenting to tax revenues being used by the Government to prevent the dissolution of the fabric and character of our churches and cathedrals.
	Secondly, the established church must do more. It must draw upon the £4,600 million tied up in its land assets and use a small percentage for capital purposes. This was true in the 19th century when many churches were built using the capital from those land assets, and it would be a small dent in that land block. It is imperative that it contributes by matchingand complementing the work of the wonderful but diminishing congregations who work so hard to find church funds. We must have more imaginative ideas, like civil awards for church wardens, administrators, roofers, builders, gardeners and those who have given their time and skill in lieu of money to save their local church. The local authority could have the responsibility for giving out such awards.
	The churches must be more open to non-church activities that are nevertheless respectful of the church as a place of worship. I congratulate the right reverend Prelate the Bishop of London on the reopened St George's, Bloomsbury, which, according to the Camden New Journal, is now hosting a chess night for youngsters and another chess night for unsung Boris Spasskys who play chess, like me. In the longer term, when leasing part of the general church estate, the church must be prepared to work more and serve with others in the community who have an interest in using these buildings.
	A third group of people concerned is the Government, and I hope my noble friend will respond positively tonight. The Government must play a larger role in thinking about this longer planning. I know there is reluctance on their part because they see what has happened in France, and they are worried because in France the responsibility has fallen almost entirely to the state, but they have to be much more engaged, especially in planning, as well as providing money. They must define the criteria according to which government money is used to ensure that it is for the purposes the agreed parties have in mind and that it is properly accounted for.
	I give a final example. I can say that we in this Parliament have started at home. At the kind invitation of the noble Lord, Lord Roberts of Llandudno, I attended St Mary Undercroft on Monday evening, on our own premises, to watch young Christians from Ghana singing wonderful hymns and carols and swaying to the music. I was almost encouraged to join in the swaying, if not the singing; after all, although an atheist, I have never understood why God should have all the best tunes.

Lord Rowe-Beddoe: My Lords, I declare an interest as chairman of the Representative Body of the Church in Wales, and therefore the representative of the disestablished church that deals with the devolved Government. However, I have been encouraged by the two noble Lords from Wales to speak at this moment.
	Our problems in Wales, as noble Lords will readily recognise, are identical to those in England, although on a much smaller scale: 1,100 listed churches out of 1,500 in total. The eloquence of the noble Lord, Lord Howarth of Newport, when he used Betjeman's words to describe the churches of England and Wales, encouraged me to stand, as did the words of the noble Lord, Lord Lloyd-Webber, when he talked about British churches.
	I am inspired by Inspired! and I hope that there are elements we can take across Offa's Dyke. I urge the Government to continue their support, as well as that of the Heritage Lottery Fund, because, as we all know and as has been so eloquently said, the heritage is important. The churches are not just heritage; they should be living edifices, as the right reverend Prelate the Bishop of London illustrated. They are vital to the well-being of our community in this country: Wales, Scotland, England and, indeed, Northern Ireland.
	In addition to the trusts mentioned by the noble Lords, Lord Lloyd-Webber and Lord Shutt of Greetland, could the Government look at matched funding? I suggest that in this debate we have forgotten the enormous contribution of parishioners, in addition to what is given weekly by people of all denominations who attend services, as well as visitors. We have a very good 28 per cent tax relief scheme for our normal donations, but if we could focus on what is required for our buildings and maintenance and then do something innovative such as introduce a form of matched funding, from wherever it may come, we could really make a difference.
	As has been illustrated tonight, the gap between what we have and what we need is enormous. We will be dancing around this problem until we can look at it slightly differently.

Lord Clement-Jones: My Lords, this has been an inspiring debate. I add my thanks to the noble Lord, Lord Howarth of Newport, for initiating it. We have heard a huge range of expertise, commitment and passion—it has been quite wonderful. We have heard from a number of trustees of the bodies charged with trying to keep up the maintenance of many of our historic places of worship.
	Many of us, even though we are not churchgoers, are reminded daily of the importance of places of worship in our landscape and communities. I live in Clapham; I work in the City and here in Westminster, and every day I am surrounded by historic places of worship. Many of us have strong family ties with churches. I was fascinated to hear my noble friend Lord Roberts talk about the chapels of north Wales. Indeed, the noble Lord, Lord Rowe-Beddoe, is charged with the maintenance of many of the historic churches in Wales. The churches in north Wales with which I have a particular connection are Gresford and Wrexham—both very fine; I also have a connection with churches in Westmoreland. It is not just Christian places of worship that are affected. The right reverend Prelate the Bishop of London mentioned historic synagogues. I welcome English Heritage's Inspired! campaign, which has inspired this debate.
	Before talking about the problems of our churches, it is important to acknowledge that some existing schemes have helped; many of them have already been mentioned. The listed places of worship grant scheme returns VAT on repairs to listed places of worship; it is worth approximately £12 million per annum, as the noble Lord, Lord Howarth, pointed out. The joint repairs scheme operated by English Heritage and the Heritage Lottery Fund is worth £25 million per annum. The noble Lord, Lord Howarth, also pointed out that the Churches Conservation Trust receives£3 million in direct funding from the DCMS and funds 335 historic churches. Then there is the Historic Chapels Trust, which my noble friend Lord Shutt talked about so eloquently, and £1 million per annum is directly provided by English Heritage for cathedral repair.
	All these are good schemes, but much of the funding has fallen in real terms over the years, particularly that from English Heritage. There are other problems. When St Paul's applied to the Heritage Lottery Fund for £6 million to complete a restoration project, it was turned down, it appears, on the grounds that it was too exclusive—whatever that means. The money paid out by English Heritage over the years has steadily fallen, in line with its government grant, and now we are down to £1 million for cathedral repairs.
	In April 2005, I asked a Question specifically about cathedrals and received a rather rose-tinted Answer. But the poor state of repair of our places of worship is starker than ever. There are some 14,000 listed places of worship. English Heritage estimates that we will need £925 million over the next five years to maintain them. The Church of England estimates that £100 million will need to be spent on our cathedrals in the next five years. There are 42 cathedrals, 38 of which are listed. One million pounds seems a very small sum in relation to those liabilities and maintenance obligations. Cathedrals such as Canterbury, York, Rochester and Salisbury are in very poor shape and clearly need further funding. Those who are responsible for maintaining places of worship are concerned also about the impact of the Olympic Games on grants from the Heritage Lottery Fund, particularly as the cost of the Games seems to be escalating.
	However, we need constructively to discuss how more funding can be achieved. No particular party, let alone my own, can give an easy promise of further funding in the current climate. We have arguments within, as much as between, our parties about priorities. Faith communities and congregations raise considerable funds. Cathedrals raise funds through entrance charges. I was most interested to hear what the right reverend Prelate the Bishop of London said about fresh thinking. I was interested, too, in what the right reverend Prelate the Bishop of Southwell and Nottingham had to say on this subject. I recently read an interesting article about a business consultancy called Ecclesiastical Property Solutions which was set up in 2004 by the Reverend Andrew Mottram to assist churches in managing their properties. It is in that context that what the right reverend Prelate the Bishop of Southwell and Nottingham said about changes in consents and planning was particularly relevant.
	The Church of England made a major contribution in 2004 with its report, Building Faith in our Future, which set out what volunteers could do. As the noble Lord, Lord Roberts, said, it involves people as well as pounds. Clearly, faith groups need to be responsible, as the Culture, Media and Sport Select Committee pointed out, but, for major repairs, we must admit that existing funding through English Heritage—I think that it is common ground among all those taking part in this debate—is inadequate.
	Will the Government respond to the recommendations of that Select Committee; namely, that, in real terms, funding for English Heritage should be returned to what it was five to 10 years ago? Will the DCMS make representations—or has it already made them—to the Treasury for a further £26 million as part of the Comprehensive Spending Review, to be spent on listing activity, support officers and maintenance, as proposed in the five-point campaign of English Heritage?
	We should all listen to the injunction to us by the noble Lord, Lord Roberts, to share ideas and come together in trying to solve some of these problems. English Heritage has given a new impetus to this issue. I hope that we will take its warnings very seriously.

Lord Evans of Temple Guiting: My Lords, I thank my noble friend Lord Howarth for initiating this debate. I totally agree with the noble Lord, Lord Clement-Jones, that it has been inspiring and a major debate. What has been particularly interesting about it is the common theme or shared view that perhaps, instead of people just looking to government, government should act as a catalyst. We could all get together and think how we could raise more funds for our churches. That is a very important point, which was made by a number of noble Lords and for which I am very grateful.
	I thank the right reverend Prelates the Bishop of London and the Bishop of Southwell and Nottingham for their contributions, which, given their vested interests, were very detached and extraordinarily helpful.
	The Government take extremely seriously their responsibilities to maintain our places of worship. We want to be certain that these unique buildings are here to be enjoyed by this and future generations. Here I pay tribute to the noble Lord, Lord Lloyd-Webber, and his trust. He made a very interesting point, connected to the first point that I made, about the Government acting as a catalyst in fundraising. The Church of England has a very good website called churchcare.co.uk. DCMS officials told me after the contribution of the noble Lord, Lord Lloyd-Webber, that they will look to see how expertise can be shared further to enable the guardians of all historic faith buildings effectively to tap into resources. So that is an idea that can be developed outside this debate.
	We are talking about buildings that are the finest work of master craftsmen. We recognise that they are unique in their contribution to the nation's heritage and that, for the most part, they have been in the same continuous use for worship for many, many generations.
	We also recognise that our places of worship fulfil vital roles in communities. That point was made by practically every speaker, particularly by my noble friend Lord Harrison. As we heard, they are centres for community events where volunteers perform countless valuable functions in society such as supporting elderly people, providing advice and counselling, coffee mornings, lunch clubs and childcare. Several noble Lords mentioned these things. They are the glue that holds many communities together. Cathedrals, too, in additionto operating as places of worship, with growing congregations, and, again, doing vital work in communities, act as a major magnet for visitors to our cities.
	While there is a lot of government and Lottery help available towards the cost of major repairs—I shall come to that in a moment—we recognise that, in many cases, routine maintenance and repairs would not happen were it not for the tireless work, both practical and in fundraising, of many volunteers. That point was made many times this evening. The noble Lord, Lord Howarth, said that £70 million is raised each year and the noble Lord, Lord Roberts, described the volunteers as saints. That is a very apt description. These volunteers are selfless in their devotion to their places of worship. This sense of ownership is actually priceless, but it is not, of course, a substitute for necessary grant funding; it augments it.
	It is true to say that we know more about the state of our historic church and cathedral buildings than we do about any other group of historic buildings. Two years ago the report, Building Faith in our Future, was published. English Heritage's Inspired! campaign was mentioned by a number of noble Lords. It was a catalyst for thought. The noble Lord, Lord Shutt, mentioned its five proposals. The Government welcome the new data provided by the relevant document. However, the Government allow English Heritage the flexibility to decide how to allocate its grant of £130 million a year among its responsibilities to the historic environment it deems priorities.
	English Heritage has also worked with the Roman Catholic Church, the Methodist Church and Jewish Heritage UK to explore the significance of their respective churches and synagogues as part of the nation's heritage. I am pleased to have the opportunity to set out the unprecedented level of support for the conservation of our historic places of worship that this Government have put in place. More grant funding is dedicated to this sector of the historic environment than any other.
	Funding is made available either directly from government or though sponsored bodies. Taken together, funding for conservation of historic places of worship was well over £60 million this year. We have heard about the listed places of worship grant scheme. The scheme makes grants equivalent to the VAT incurred in repairing listed places of worship. Christian denominations benefit more in this instance simply because they have more listed buildings in their possession, as the right reverent Prelate the Bishop of London told us.
	We recently passed the milestone of £50 million having been given out under this scheme since 2001. We regularly give out over £1 million per month. Significant sums are put back into listed faith buildings. In fact, over 8,500 buildings—a large proportion of this country's historic ecclesiastical estate—have benefited. This is a temporary scheme, although it is in place until 2011. While it is in place, the Government have been and are continuing to seek agreement at European level to offer a permanently reduced VAT rate on church repairs.
	Noble Lords will also be aware that, in this year's Budget, additions were made to the scope of the scheme. Another major plank in the funding available is the joint scheme in place from English Heritageand the Heritage Lottery Fund, which has been mentioned. This year's grants total £24.5 million, which takes the total given out under this scheme since it started to almost £90 million. Over 1,000 buildings have received grants. Cathedrals also have dedicated funding in place for repair from English Heritage. Some £42 million has been given out since 1991, and support continues at £1 million per year, which is to be generously matched for the next three years by the Wolfson Foundation.
	I should mention also the landfill tax credit scheme, which has not been mentioned this evening. Landfill operators are encouraged and enabled to support a wide range of environmental projects by being given a 90 per cent tax credit against their donations to environmental bodies. Churches within 10 miles of a landfill site can benefit. In fact, over£17 million has been disbursed to faith groups in this way. We have heard about the Churches Conservation Trust, where £3 million a year is given out, and we have also talked about the Heritage Lottery Fund. My noble friend Lord Howarth mentioned that yesterday the HLF renewed its commitment to funding in places of worship with a £20 million grant for 2008, and a dedicated funding programme for places of worship that takes us through to 2013.
	A point was raised by a number of noble Lords about the heritage protection review, and they mentioned the idea that planning matters should be made far simpler. The right reverend Prelate the Bishop of Southwell and Nottingham asked how we can reduce the administrative burdens on churches associated with adapting buildings to meet future challenges. The Government are keen to assist where possible in reducing those burdens. Already, under the ecclesiastical exemption, the major denominations are exempt from the need to obtain listed building consents for work to their historic church buildings.
	The Government have now reviewed the ways in which we protect all our historic buildings, and this will be the subject of a White Paper to be published shortly. The White Paper will set out our proposals for a new heritage system that is simpler, more open and flexible. The White Paper will address a range of issues, including the burden of current consent regimes and the scope for management agreements to reduce that burden. The churches, as they seek to engage more with local communities' heritage partnership agreements, will provide the opportunity to remove the need for repeated consent applications for the kind of work that crops up regularly over time or which might be needed at different sites. We accept that there is a problem here, and we are going to do something about it.
	The noble Lord, Lord Clement-Jones, raised the point about St Paul's Cathedral's request being rejected by the Heritage Lottery Fund. What he said was not quite accurate, but I will give him the note afterwards so that he can read it.
	In conclusion, we will continue to work with the Church of England, with the other Christian denominations, and with the other faith groups, both directly and via our sponsored bodies, to explore how we can secure together a sustainable future for all our historic places of worship. As a gloss on that final paragraph, the idea that has emerged this evening from a number of noble Lords about working together, coming up with new ideas, and using the Government as a catalyst is extremely valuable. I am most grateful to all noble Lords for their contributions to what has been a really fascinating short debate.